GW1--03344_Well Construction - GW1_20230512

WELL CONSTRUCTION RECORD Fiji intcnutl Use ONLY:
Th s form can be vwd far sine Ic or oodtiplc was
i
1.Well Contractor Information:
..MAVM1TERZONES C
John Eisenman FROST TO DF'SC'RfP7Y0\
1Ve11 COIAtaC10r Name ft. ft.
4439
NC%Yell Conlr!nor Ccniticatiou NIU bey '15'Ot11 ER CAStNG'tf�irtiirih[atY4ed iictls}'OR LiNFR Rf a i"ll&bkl' •:---
FROb1 TO Dt:\A'IiTF.R THICKNEM \1At AL
SAEDACCO Inc fL rl.
Con jrmy Nano 36.INNER'CASiNG OR.TIJSING:('eeolhairrnyl claked-bip');','
FROM TO DMAIF.TER TIIICANF.SS MATERUL
2,Wc1t Coustr•uctilut Pcrtnit N. N/A 0 R. 4o ft, 2° BL SCH-4o PVC
1.a all r•)phru6far welipenmirs(i.e.CowitY.Slater,Yarirarre,lry2t6'wl en.) - R, ft. is
3.Will Use(check well use): 17:SCRF EN:i
Water Supply Well: FltOrl TO DiANIETER sIM8171 sIATF;Rt.a1.
DAgficulturnl ❑Municipalr•Public 40 ft. 50 fi- 2" ht• .010 SCH-40 PVC
DGcothemlal(Healing-Cooling Supply) ❑Residential Water Supply(single) ri, fL in,
DlndustdaUContutcrcial DRcsidential Water Supply(slatted) J8f;GROUT
PROM TO NU\TERL%L I E1fPLAMNIF-NT 1IETIIOIY t A.SIOUNT
❑Irrt°tttrnn 0 fL 34 fL Portland pour
Non-Water Supply Well: «, n.
®hlmlitoring ❑Rccm'cq•
Injection Well: ft. rL
❑Aquifcr Rccharge ❑CJrollndw;alcr RClncdimion i19 SANDIC.RAVEL'PACI<Crf 'i'itKyhtaa)t:
FROM TO SIATF.Itt•11. F:SIPLACY.\lY:\T\IFTEtnII
❑Agotfcr Srorage Ind Rccovvy ❑Salinity 81rdrr 38 R. 5o (I. Sand #2
❑Agltifcr Tcst ❑Slorinwotcr i?nonage ft. ft.
❑Experimental Tio;hnology ❑Sithsidcm:c Cordial
:2o�ORILLINC'LOG'fiittadi`iidditioa"ill sheets if nccessaril -:" -
❑GLothenmd(ClusedLoup) ❑Trlcer FRONT TO DF5CRIPTIUN ravbr,hanlnc++xtLenack tr t. Mn arc.ttr.1
❑Geotliennal(IleatingrCuoline Return) ❑Outer leXplairt under#21 Retuarhs) 0 fL 50 rL Silt/sand/clay
rt. iL
d.DateW'elt(s)Complcled: 2-17-23 Well IDOW-40A
. Ft
5a Well faYcatiuu: _
rL f, C C s
Corning Glass Works N/A MAY 1 2 LULUL3
FacililyiQvncrNantc FacililyID„u(if applicable)
3900 Electronics Drive, Raleigh, NC, 27604 .�
g ft, ft. Giti3rtw: '�11:?V •.
Phrskal Addmss.City.and Zip 21 RREMARKS.'
Wake N/A Bentonite seal 34-38'
Calmly 1 Amd ILL31 irte:11iuu No.(PIN)
51).Latitude and 1.011gitu41c in tlemreslminutcsJsccnnds nr decimal d
Of ucll IBM,uah!h0mig k sadlici_eni} 2� CCttlf[l`It11.Yn:
35.830758 N -78.603564 W 3/2/2023
..
Date
6.is(are)We well(s)t ]Permanent or ❑Tenelloran'
M srcrrnag.v,as Pen. �•caah•ri:r':+.,:�� s L:r:r)a�rminre7erl ilr r•erarrlmtcr
ndTa}r.f:t NC+(C OTC.'x�.•:��'r: ;ff.'i�4.�ro l',{7:r7f7 IYrrl Consrr�arrir�rl Sfnryrrrrirs<ral ri trpu<r
7.is this a repair to an exiatingwell- ❑Yev or ENT► rein ofthix r<vnrdraaslrrn rigrrir4af rn l r n rr rnrnr•r.
lfrrris ix a ralxlrr,trra><ar,arraa7,arrrrraars7rni,ina rarftea7r47rrrr,l arraar e.cprrahr rhr reamer rafrlir
repairaarder,021 rrmarkvwrliora or rm nce hark.nrrhrs farm. 23.Site diagram or additional well details:
You may use the back of this p:Ege to provide additional well site details or well
8.Number of wells coustniLted: 1 construction details. You ttlav also allachadditnilhil pages if necessary'.
Fur maniple rajee-rion&nevi-nnrer rnpplr beets ONLY mNli the same construrdoit.syarar r•aw
xrarrurirone foma. SUBMITTAL iNST TCTiONS
9.Total well depth below land surface: 50 (ft,) 24:L For All Wells: Sabudl This funn \cilllin 30 days of completion of well
For maniple iedA rise fell aleprrrr ifdrl4ivr,lr(c�rurgrra•-3@ 09'and 2F14-4)•) construction to the following:
Ill.Static water level below lap of casing: 26.32 (ly) Division of Water Resources,infortnation Pruccssing,Unit_.
if neurr never h rebore easing.rite'•+" 1617 Mail Set-vier Center,Raleigh,NC 27699-1617
11.Borehole diatneirn 8.25° (ia) 24b.Ed InfiNflQuN elk ONLY:I in addition to sending elk foml to the address in
24a above.also submit a cop% of this form within 30 days of completion of well
12.Well construction inahod:BSA coustmt-lirnl to the following:
(i.c.auger.rolaty,cable dim-%push etc.r
Division of Water Rciourt'es Underground injeclion Control ProgrAul,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699-1636
11L Yield kvptn) Method of test: 21c.For Watcr Supply&Injection Wells:
Also submit one Copy of this funn within 3o days of completion of
13h.Disinfection type: Amount:— well construction to the county health depanmem or the county wlrcte
conslmcted.
Form G%V-t Noah Carolina Depanllwm of Enearonnkut and Natural Resources-Div vion of 1 raler Reorres Revised Augus±2ttl i