GW1--03259_Well Construction - GW1_20230511

WELL CONSTRUc'riON RECORD Fes-lt'3zftkalUscONLY:
iitis farm can be tmil Far.single or mullip)c mils- `` ►An_
1.Welt.Cuntrnctor Information: `v`
WA CIM ZONES .
John Eisenman MOM 1.0 orscitt"10111
W01CommoarA;trm o. I R,
9439 ft. (L
NC-Nell ConImclorCCrtif=tion Nuir,bcr M,011TER CASfA1G Ifni mufti e�ertl ctlsl OR L1NER'fif a''gcs6kl'.
FRONT I TO DFAMETER 7NICKNESS MATERIAL
SAEDACCO Inc 0 f4- 30 (L 2" in. SCH-40 PVC
C<tnt}run N we -16.INNER CASING OR TUBING:`•R*Immm d cfascd-tanja '
FROM 1 70 DMNIETER I 7HIMNF.SS MATERML
2,Nvclt Coasttuction 1'elu»t 4: R,
Life Rll.:lpalirab1ewellprhafti fix.Coimr%�Swe,11(rrian e,lr�erdtR3en.l R. (t. tie
3.NVCI11;aQ(chcckivdl asc)7 I7.SCREEN -
Water Sn[glly Well: FROM 1 70 1 atAMUM I St,OTS173; I 11110ciRl '5 NLtTt2RrA4
riAgdcultumi rJ)Vluti[c[patbl'Itblic 30 ft, 40 ft. 2.1 in. 010 SCH-40 1 PVC
®Geo(hetnxit dieatingtooliog Supply) ©Residential Water Supply(single]
©TudnstriaUf°otnnun:ial ©Residential eater Supple•(sl>simd) �18.
FROM TO NLtTER[hL EMPLACENfENT UE111011 ,LWOUNT
❑Irri ition 0 ft. 23 ft. Portland Pour
Nate- ate'rSupply NV911: tt: ft 1
6illvlanifnnn9 pRc m cly
IaJeetlon Wet[: ft. FL
QAquiferRcchargc :I4i SANDIGI L'PACKYifu't el
Et:tlM 7CI NLt•rlCn l li\IPI tC.ltrt:NTMEITIna
❑Agnifcr Stotagc and Rccov ty 0salinity Biniet 28 ft. 40 (4 Sand i12
❑Aquifer Test gStomittatcrdrti141!c ft. ft.
❑Ex[rtfutculal TMinotogy QS%tbsidcncc Central
lfi.IDRILLING'LUG(allkh'ad4110 A sheets if itecr wn t
OG:eotlienmd(ClosedLuup) ❑Tntcrr FROM To 11MCIUMON,ko%ar.h;tnl14c+4,94,1110ahai".-It Vk"COa)
[711 othenual(HentiuuCaoling Retmn) ❑OdLer.(explaitt under#21 Retuatks) 0 f4. 40 IL clay/sand-
fL (L
4.Date WeN(s)Couipleled: 4-14-23 Wet[1DgMW-1 (t: ft.
So.Well LmcaiOn: fL ft. °. 4 d e
37
%7
Action Graphics 6 Signs f4 (4 pp,��Qt�f�l
Facilitp,0%sncrNtuuc Facilityb4 ifapplk;ible) `t1I 2023
603 Roxboro Rd., Oxford, NC, 27565 ft. ft. a
PlnsialrlrLdtdssCity-and Zip ' t •� "�"n �f~r �7UO�
21 RENIARKS- as ram`'
Granville bentonite seal from 23-28 ft
Calmly I'ArcelldcrUiftcalionNa,(Pk)
ill,T.atitudc and Longittlila in dcgrecs/minutes/seconds at,dccinval dcgl ccs: 23.Certification:
(ifaelll-x.W,Ong lal.1pugi%stdlick o)
b` W` _ _ �� - - - 4/27/2023
Dale
().Is(arc)the tt•ell(a),t %IPennanent r]r ❑Temlrorary' 1h s;Gniri hir fur;:__F� :,5_r--r;t .t. ej cv..-md ltr..ri eorru M
trtih fSa NCrk:flla,.�r-�:��'1 e':'�Gri��:3L,!)iQO tt l'IJ C17ryS(r7r1'71PII Sk111!l2{r115({llff 11,417a
7.Is this arepairfuadexi ding ivelli !❑b'e.N or ENo ftyrrnlrftiriorco flidshrrnpmvitledr6)&mW railer,
If M(s'l,i?mpak,fill Tarr 0moi trcllrnturrucri:t;a!t{jurrrxrrlwt,�,d r.tlrinln rAe rtuarre of.dir .
relirirmr lrr d?t'rcrriarCs srceeun orc�a nc�LruE ofrlur form 23,Site diag1'ain or dditionlll welld@taili:
You may.use the back of this pa.ge to ptovide AM'1i9nat%sell site delails.or ii•e[[
S.Ntunberof%fells constructed: 1 coustfuction derails, You roar aLa atladt additional pa&s if thcessary.
For rrynhiple adetrkot err orut-nwrer supply wren,4RE Y n'idi the smite cetrrsm(crion,yoat mrr
s�frutirerur.fnrrr. SUBMITTAL.fNSTETCTIONR
9.Total Well depth below laud sdrfrici: _ 40 (ft.) 2-fa: For All Wells: Subinit Mils fann within 3t1 days of compledou of well.
For itutlrlvleicelhlfsrrrlldepthsirdifferrrulcs:rrrt k=.;�:p(1'<rrkl2r�sllu)'► constAmtiontotlicfoitottiugr:
to.Static water level below tall of casing (ft.) Division of Water Reznukes,Information Proeming Unit,
tf ua;er level 1,vbuec +" 1611 Mail Service Cvater,Raleighi Ne 2i699-I617
ll.Borehole diameter 6" [ia) tab.FniE Jf)f�€Il1Ltt tr4'gtLc ONLY: In addition to send[ng 1lte foRu to the addms in
24aabote. also submit a copy of this fonu within 30 days of completion of atilt
12,Nell constmetiou metlood:Air coustmction to[lie follow ine:
fi.c.auger iotmy,cable.direct posh.etc.1
D[t'isioll of Water Resmirces,Undergronnd[meat Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centcr,Raleigh,NC 27699-1636
130,Field()1m) "Wdlad of rest: 24r.Vol,Water SupLh.&1n-ie50oti.Wells.
Also submit'one copy' of this 156n tcithht 36.days of completion of
well.can9tmction to the caunty'hcalth department
rtment of the colmty when13b.Disinfection type: Amount connccd,Fanu Gt\r-t Nonli Carolhta Dcpaamcm of Eudroarucm and Natural Resources-Division of Walt r R--atr, Rimsed dug m 2U13