GW1--03349_Well Construction - GW1_20230512

WELL CONSTRUCTION RECORD Farfl�cnut9UscONLY:
This forntcan t>v u5cd for single or multlplc wdIs
1,Well Contractor information:
I4.1VATER.ZONFS
John Eisenman FROM 'to 0FS('RIPt1oN
1t'e1 Coryrtoor Nantc
4439
NC Wd]ConlractorCcnifkalimt Nuni,er
t&'OUTERCASINGtGi'iiiiiHlcJell" eitc5''ORLINER(fti}'"'tleabkf
FPOM TO TIMMT;TF.R TT1iCt{NFSS MATEPTAL
SAEDACCO Inc 0 fL 159 fL 6" in. SCH-80 PVC
(:angram)-Name -1CINNER'CAS1119GOR'TU81NG: `eoidcrindeMsedaoii`
FROM TO DLt51F.TER THICKNESS MATERIAL
2,Wcll Construction Permit#, N/A 0 ft. 165 ft, 2" ill. SCH-40 PVC
Isar id!(q plirnFle vcll prnmirs ti-c.G,rntr,..Stm:,l yriarcr,!r}ECb't4a r�:i n ft,
3.Well Usc(check well use): 173CRE EN
WaterSupply''"Iel: FROM I TO I DURF.TFR I SLOTS11% I TfuCHMSs MATRRIM,
❑Agdcultural CllefunicipaUl'ttblic 165 A, 175 f1. 2" in• .010 SCH-40 PVC
❑Geothennal(HeatingtCoolins Supply) ❑Residential Watcr Supply'(singic) ft. fL
OluduslOWConmttcrcial 131ktaidentiat Water Supply(sbatcd) :TBi GROUT
FRONT TO AtATERUL ExwLicEMFNTkIETHODdAMOUNT
❑Irri-g•ation 0 ft. 3 fL Portland pour
Non-Water Supply Well: 3 (t, 159 ft, Aqua Guard Tremie
®hfoniloring ❑Rccot'ey
Injectlon Well; fL (L
13AquifcrRcchacgc 13Groundw;ticrRcnrcdiation '14'SANDIGRAVELPACIiTirui)Iie�Atei':;
FROM To NIATF:RIM, F:MPLdC:ftlkNT M}:7110Ir '
❑AgtrifcrStortgcattdRccnvrt}' ❑Salinity'Uarricr 3.63 ft. 1 175 A. Sand #2
❑Aquifer Tcst ❑Stosnwwatcrdrrltnagc
❑E r.crirucntnl Technology ❑Stthsid_ncc Cardrtfl
❑Getlthcmral Closed Loop) ❑TrrceK "1a DRILLiirGLOG fnu:tcti addition"slLehcets f iicccssa'r�t: - :. .-
FROM TO DE5CRTPTION hube,hyr,lne�•wd4'rnck h .- "n WC.vac l
❑Cn'odictinal(HeatingrCuoliu_L'Return) ❑Outer(explain Maier k21 RetuarLs) 0 fL 60 fL clay/sand
60 ft, 73 ft. PWR
4.Date Well(9)Completed: 4-5-23 WelllD#MW-40D 73 it. 175 fL Rock
ia.Well tAlcrtion: r ai ft. ft. L� �I—;
0 i ,�_.a3 it i%
Corning Glass Works N/A fL it. M�Y i '�
Facility',Y_ttencrNaive Facilit-IM"(irapplimble) ft. ft.
3900 Electronics Drive, Raleigh, NC, 27604
fL A. ltl�iri"n,'S:;^l . C.^.::J:°<:"r r.
nil
Ph)sical Addmm Cite.and Zip 'REMARKS'.
Wake N/A Bentonite seal 159-1631
C:onnlY Parcel Ide-3011 11ipnNo.(FIN)
56.I atitudc anOl Long
itu lc in lira r'eccEminutcs/seconds or decimal itegrees: 22.Certification:
(itoell fiaW,011L lablouLz is tirdlicianl}
35.830758 N -78.603564 ��• _ -' 3/8/2023
SIgn3hlT or'`--r.h+...'.)i- uu_...a.•— - 11afC
6.is(are)the well(s): 10Perinanent or ❑Tent1 oran f
N a:.gnin�mN.r(can:�r,:�l¢�'�ih't�r':-rr a �J�-�r:�i wr�rnrerrr/ire rcx•anknre
1VO4 l sd NCtC 02C. '-jc,)1ao trill Conserarrim Srarr anh and i1mra
7.isthisa repair toAnexlstingwel1: Oyes or INNr1 IN,gr•llowner.
if this it r rgvdr,fill opr kr•alga u'rU eolwimC11'"a irrfurowthm and arpea i rite nur'aer ofrin•
rapair tinder#21 remarkvxeraiar.or cut the hr:rt rtrtlrix form. 23.Site diagram or additional well details:
You may use the back of this p ge to provide additional well site details or teell
8.Number of wells constructed: 1 construction details. You inav also attach additional page s if n-, essary.
For ttudrWe u�evrlmn?r euvi-iruter srrpp{r aeffs U,NL1'n'lrh the stare eottsrrurrivat.}'oat van
saimtieaneforn. SUBMITTAL INSTU .TfONS
9.Totat well depth below land surface. 175 (ft.) 24a. Par All Wells: Submit this furor within 30 days of completion of well
For IttaNple I.•rUs lisr tell depts ifdiJ,1i-re•a1F ler=nnple-3q:tk)'w412@1fta)'1 constmction to the following:
10.Static water level below(up of cming7 24.12 (ft.) Division of Water Resources,Information Processing Unit.
if ieclnv level is shove cvrsoX,n_-e"+" 1617 Mail Service Center..R leigh,NC 27699-1617
11.Borehole diameter:12"/6" (in.) 24b.Dr hthlinn WON ONLY: iR addition to sending the foml to the addrmss in
24a above. also submit a copy of this fonn within "days of completion of well
12.Weil coustroction method:HSA/AIR construction to the following:
(i.e.anger.slur),,cable-dimcf push ete.l
Division of Water Resources,Underaground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
1341.Yield kTru) A4ethUll of test: 21c For Water Supply&Infection Wells:
Also submit one copy of this f6fin within 3o1 days of completion of
13h.Disinfection type: _ Amount: w'ctl construction to a1c county health dcpanment of the coumy w hcry
—' constmctcd.
Fana G%V-t Nonh Carutiani Dcpanntent of Enorowncrti and Natrrrd Resources-Divaion of 1Yalcr Renotrces Revised august 111t:1