GW1--03348_Well Construction - GW1_20230512

i
WELL CONS'TRUC'TION RECORD For trtertml Use ONLY: '
Tli s form can b:used for stogie or multiple wcils
1.Well Contractor information:
IJaNr'%MKZONES: ! ,.
John Eisenman FROM TO DFSC'HtPt'u)\
%Yell Commulor Name ft. ft.
4439 fL f1.
NCNVr1lConlractorCcnificationNuniur 111S.MTERCASING(for;iiiiiflTca!ieilKcFIs1ORLiNERCif i iikabkT'
FROM TO DL�METF.R Tr11CKNES,! MATERTAL
SAEDACCO Inc 0 fL 57 fL 6° in. SCE-40 PVC
('aniputs-Name I6:11NNER'CASINGORTOBING' i i6ertitytctuscilLld't '. _ '
FROM To DIAHF.TER THICKNESS MATERIAL
2.Welt Con.1tructiarr Pcrmit 4: N/A 0 ft, 6o R. 2° rL SCH-40 PVC
I-waft gMhrahLr KWI pawdtr(i-c.Cmourc_.Thev,Yadarm-t iry"-,Cn fir.I ft, ft.
trL
3,Welttisc(chtxl;well use);
Water Supply Well: MOM I TO I DiAStF:M StOtSIZE TRICUMSS I MATF:RIAL
❑Agriculttllal LiMunicilml.- ltblic 60 ft. 70 ff. 2° in, .010 SCH-40 PVC
❑Gcothemral(Flea(itrg,'iCooling Supply) OResidential Water Supply(single) 1
(1, 1 fL in,
Oludustriab'Commcrcial DRevidencial Witcr Supply(slram-d) -4BSGROUT,
FROM To MATERIAL Xft L.ACEXIL \IMIOD S AMOUNT
Ellnifultian 0 ft. 3 fL Portland pour
Non-Water Supply Welt. 3 ft. 54 ft. Aqua Guard Tremie
Mklonitoring OR.-co-cry
injection Well: ft. ft.
❑Reiter 11cchagc: 00roiintfi atcr Reutcdiation 493ANDIGRAVEL3'ACK(if' "rNidabtcl:``
FROM TO I NixmRmm. 51PIA(7:H►:VT MF:rRnn
❑Aquifer S(orlgc aril Rccovcry ❑Salinity Barrier 58 ft, 70 A, Sand #2
❑AglliferTcst ❑Stmmm:ttcrDnitinagc ft. ft,
❑E.ylctintcriml Tctihnology ❑Subsidmicc Control
❑Crro[herotal Clused Lau ❑Trav er 1fl.'DRtLL1A'CLOG'flit�ach"iidrtitioiidt�liLYts if ritccsv irirT
( p) FROM TU pESCRiPTiUN gebr,ptnlaca,rdrtntcAh t. n dre.dGl
❑Gcilthen[rill(HC8IIl1UCooliue Retunt) ❑Other(explain inkier#21 Retuad sl 0 R. 35 fL clay/sand
35 it, 65 ft. PWR
4.Date Well(9)Completed: 3-8-23 Well iD#MW-42B 65 ft. 70 (L Rock
5a.%W41 Location: ft. ft.
Corning Glass Works N/A fL fL ,
Facilul•,Ua•ncrNave Facilit)•1D:(if applicable) R. rl. mALY 1 e' ZQ
3900 Electronics Drive, Raleigh, NC, 27604 ft, ff.
Physical Address.City-and Zip
21 RE6IARKS'•,. t
Wake N/A Bentonite seal 54-58' -
Cautly Parral Id_nlirkc9ill n No.(PIN)
5h,Latitude anti imigitule in 411c.p'es(minutcs+scconds or decimal drygives: 22.Certification:
(If,�cn Feld,ow,I:bbtig iv stdlicknl)
35.830758 N -78.603564 3/15/2023
Sie r tutuof"=_. 'e.� JI('u�;�`•s.`— -- Dale
6.Ls(are.)the we11(s}: M- Pennanent or ❑Temporal} '
n f na�. .•i.:r:.:r.eanmrrrrdfn r�cvtrlrrnrr•
u ir4!S t NCAC 0.1C :�C A,.-.f C{?�(N7 tli'lJ Cngslrrrriun$fnue(dt:(s<ulrl rltt t u
7.Ce this a repair to an existing well: :7Y�w or NNo r,vr ofrhir rermil hos here pmvided rat%a xadl mener,
if;leis rs r rtlwir,flf fair 4gmm it-ell['CrtAmaimn ltffol-mm,'tnt ued ef((nht the murarr of f it
reprir atrder 921 rrmarke are iar or rm due hm-k-of 10s fern. 23.Site dinji-ram or additional well details:
YOU may'use live back of this page to provide additional well site detaits or well
8.Number of wells constructed: 1 construction delaits. YOU nlay also:Mach additional pages if necessan'.
For tttidtlpre or ltvrhrn at eat-confer supple writs O,�'LY'u'Jdi du urine cotrstrurtiotr.}yell rao
subuurone fore.,. SUBMITTAL iNSCIM MONS
9.Total welt depth below land mirGtte: 70 (ff.) 24a. For All Wells: Subndl this funu within 3U days of completion of welt
For ittaNple calls lin roil deprh,iJ diJ i're•nr(a,r tr,•tpr•'-J.& 00'Attu(2@ Im') construction to lltc followny
ICI.Static writer level below top of casing;: 35.58 (ft.) Dh isiun of Water Rcroure",Information Processing Unit,
If arum,level is vbove rmt'ag,me '+" 1617 Alai)Service Center.tt lei„h,NC 2 7 699-16 17
11.Borehole diameter 12"/6° (ia) 24b.Fnr hrrt'clism M4 llv ONLY. [it addition to sending tlw form to the address in
24a above.also submit a copy of this form within 30 days of completion of tall
12,Well cotistntctiou method:HSA/AIR eonstmctiun to flue following:
(i.e.augur.rolafy,cable.direct poslL c[c.t
Division of Water Resources,6iderground Injection Control Pnigraur,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service tenter.Raleigh,NC 27699-1636
13:i,Y idd(t,71n1) Method of test: 21e.For Water Supply Af inimt(nn WclLs:
Also submit one copy of this form tvithitt 30 days of completion of
13h.Disinfection tree: Amount. w'cll construction to the county health dcpanment of the county where,
-- -- coostructcd.
Font GR'-1 Nonh Carolina D.iranmcat of Environunem and Natural Resources-Divi0onof%)rater RmotrnES Revised Augu5<_Y>I:1