GW1--03350_Well Construction - GW1_20230512

WELL CONSTRUCTION RECORD For(lacnull Use ONLY:
ThEi ronn can tc.iiwd for single or niuMpk%vdls
1.Weli Contrutor Information:
Id:WATER ZONES- t
John Eisertman FROST TO nF.y(•RIP"ON
%M01 Coraricior Naric ft. A.
4439 ft. f.
NCtYdlCanlrictarCcnificationNunicr .`li•OUlERMCAS[IVG'fu"r.�iiitticastiLKePsIQRt1NER(ifa"flca6kl
FRO TO DFA�IETF.R I'll K49 MATERT.kt.
SAEDACCO Inc 0 ft, 1 183 ft. 6n in. SCE-80 PVC
Camp:ui)•Name a6 I1NNER:CASING OR'MING(eoih¢taiid'elosedaohii-:
FROM TO MAMETER T[IICRI s MATERIAL
2,}Yell Construction Pcr'nllt 9: NSA 0 ft. 195 ft. 2" bL SCH-40 PVC
List erfl alT,lirnbl r M'It lrenailI Ii_e..Catatty..Slm.4•,tilrrattt e.Iryerticn em••J
n, n, ltt.
3.}Yell Usc(ehcelcwcll usc); 17.SCREEN:
Water Supply Well- FROM I TO at-vitimpit I SL(1Tyt7}: TRICNMI5 I MATERIAL
❑AETiculturtl ❑lvltmicilmliPublic 195 ft. 210 ff. 2" in. 010 SCH-40 PVC
❑Geo(hennal(gleadrfg'Cooling Supply) 011 sidential Water Supply(single) ft. ft.
0111duslrialfConmlcrcial OResidential'1Ya(cr Supply(slxlrcd) k-GROUT-.<,;::
FROM TO SLATERG%L EMPEACEHENT SIM101):C AMOUNT
01nigation 0 ft. 3 ft. Portland pour
Non-Water Supply Well.
3 ft, 188 ft, Aqua Guard Tremie
Mlonitorillit ❑RtSa%'cr' _
Injection Well: ft. rL
❑AgttifcrRccharge ❑GroundttatcrRenlcdiati0tl :14_S.UVU1GIt�VE14CACh'fif itti yhte)" ;.-.s=
FROM To Nt,rrt etm, F:SIPI tiMAWNT ME7m)tl
❑Agoifcr5tortgc;tn�iRRo�'cq' ❑5alinin Barrier 192 ft. 210 (1, Sand #2
❑AquifcrTesi 051onmeatcrDrtinage
❑E Tcrinicnt,'rl Technology ❑Srtbsidcncc Comrul ___...
2a11R1LL1NG'LOG'fatlacd edilltitiintlslirett if ncceuiri•) :- -
❑Cre0[hett1L'tl(Closed Loop) ❑Trager FROM I TO nESCItIPT1U\rt»hn Fnnlncu rdfntckfl -,-qdn rite.t/a1
❑Geotherulal(Heating+Cooling Mum) ❑Other(explain under#21 Retuaiks) 0 ft. 25 I'L clay/sand
25 ft, 50 fL PWR
d.DateWeU(s)Complelcd: 3-30-23 WL41lD#MY1-43D 50 it, 210 (L Rock
ia.H'ell Ltrcation: ft. ri °0'A a �
Corning Glass Works N/A ft. fL FaciI11y,K1wmrNuntc Facility IDR'(if applimblc) MAY=-a.910D__
ft, fl.
3900 Electronics Drive, Raleigh, NC, 27604 ft. ff.
Phi sisal Address.City.and Zip :21:RE5VLRKS'.
Wake N/A Bentonite seal 188-192'
Cauul) Pitcel Ido,mtific ilinn No.(PIN)
ib.Iattitudc and Longlaide in 22.Certification:
(Il'ucll tKld,Otto,11Lb7tmg I%strllicknl)
35.830758 n -78.603564 }}" -=` - 4-12-23
signatumy"i„ ,r_.. Dale
6.Is(are)the%r'cll(s}: EPennanent or ❑Tetoptrran' 'a .f3 .-rr-�sc�-a
llr signh,�ties(er„r.`r•.i• ;ire., ;; s t,:r::r.rryrrurrrd hr avcvru'rnce
Iri„)r s 7:l JVCAC 02C•' i�� • Fl--cA ::..'l' Constrt
,02N)11'elj rcrit l Sraol(l ils and Ingo<r
7.Lcthisa repair toane.Tistingwell. ❑Yeti or NNo (-qqnrrhisrerattihr,;vInenprInhh-drn IN,urllrnrgar.
If this it a redktlr,fil(('w kr,otrn wellcaasu](Maa hfformeerif„i and rsr4abi the nar,,re of the
repair imder 021 rernarkv.%ve iaa ar at the hruk of this farm. 23.S ite d lagrant or additional well delaits:
You may use the back of this paste to provide additional well site details or well
8.Number of%sells constructed: 1 construction details. You stay'also attach additional pastes if tr.�essan.
ForrtndrVe rtrjavh,)i cN am-n<uer sitpplr wells ONLY n9rh fir saarEcorrsMmclio+t.}iat edlo
.safmi twee form. SUBMITTAL I'NSTUCTIONS
9.Total well depth below hand surface. 210 (ft.) 24a. Fur All }Telly: Subttdl this fetid within 30 days of compaction of%sell
For mtllrilrlemeNslitfdflepOrildfh'I•re'mr construction to the following:
1(I.Static water level below lop of casing: 61.52 (fl.) D(viviun of Water Reruurees,lnformatian Pooeessing,Unit,
l,.funter level if rebare LU11,11,,am"+" 1617 Mail Service Center,Raleigh,NC.2 7 699-1 6 17
11.Barchole diameter.12"/6" (in.) 24b.For Inhy.l(on WClly ONLY: In addition to sending the form to the address in
24a above. also submit a copy of this form within 10 days of completion of well
12,Well constructioR method:HSA/AIR construction to rite following.
(i.e.auger.rclary,cable direct posh era t
Division of Water Resource's,Underground Injection Control ProgrAnt,
FOR WATER SUPPLY}YELLS ONLY: 1636 Mail.Service Center.Raleigh,NC 27699-1636
13•L Yidd(gpm) \lcdtotl of text' 21c.For Water SunPI)&IgicctIon.}Yclls:
Also submit one copy of this form Within 30 days of completion of
13h.Disinfection h-pe: Amrulnt• wctl construction to[tic county heallh dcpannrettt or rite counh'where
— — — � canstntctcd. I
Fonn G1,Y-t Nonh Carolina Mpantneut of Ent irowikta and Manful Resources-Division orNVIler RL-o rC6 Revised August_NM