GW1--04992_Well Construction - GW1_20230807

WELL CONSTRUCTION RECOEiD �t13 FultrfernalUscONLY:
This fortn cam be used for single or molt ip c wens.
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1.Wcll:Crintractor Information:
•
-,TJ.WA'rERzONEs .
John Eisenman rows] TO nr_S(,IttP1-I11N •
Weft Coi•4ractor home. ft. 'ft.
ft. ft.
4439
NC Well ConttaclorCcnift pion Nunlicr • °tS:OUTER CASiNG(fort:(ultl-ra:c1I Oi s)OR LiNER'tit in) ticaMkl• .. . .
FROM To • nr.•tittRTea THICKNESS 51►Ta ntaL
SAEDACCO ft. ft.- In
• Coltman).Narmr . t6 1NR.0 NEAS IIG OR TUBING tgeciitscrmul eked-Idija}'
' FROM TO IMASfRTER TlriCKNESS MATERIAL
2.Wc1t Construction Permit Oh 0 R. ~5 II. 2 in. SCH-40 PVC
i si rift applicable we'permits(Le.County.Sra!e,Variaore.frya:t1C/t an, •R.• ft, in.
• 3.'Wclt bsc(chectewell Use): • • • 17:SCREEN • • • •
Water Supply Well: FROM TO fIAMF:TER sr.f)TStzs: I TRtCIeNF1S I M AI-PM:M.•
°JAgricultunti . ONItinicipal/Pubiic 5 rt. 15 ft: 2 it! 010 SCH-40 PVC
• ©Geotliertrtat(Ideating/Cooling Supply) .ClResidential•Water Supply(single) ' • 11' ft. in, I -
DIndustrial/Coatntcrcial ®Residential Water Supply(shared) Talc GROUT; .-
FROM TO. MATERIAL i EMPLtCEMLNT3IEf11101:1 4AN1OUNT
CI Irrigation . . . . . . . . . . 0 ft. 3 . .ft. Portland. Pour
NetT-Watcr Supply Weit: • .
•
ft. ft.
t0Moni(oting ❑Recovery .
Injection Well: . ft. ft..
❑Aquifer Recharge • QGroundaater Reinediatiott '1.v:SANbitatAVLL.PACifitifapplicabtt:)° . -
I.FROM TO • ( :MATERIAL d%vlPLIr:IA EN1'MI7nno
❑Armafcr.Stordgc and Recovery °Salinity Hairi_cr 4 ft. 15 ft. sand #2
❑Agnifer Test ❑Siomwv atcr Dininage .
. . tt.. . it.
❑Expetfnicntal Technology I3Suhiidence Control
20,DRILLING•WG'fnttacli-addl ioaal sheets-if itceessnrvl
❑Geotltennal(Closed Luupj . °Tracer Fn051 I TO - • PE.SCRWPTIT U\(U,tar.',atones+,stamic4ft PC.'rdn!ail:,d m
❑Geotlictnlal(Heating/Cuoliue.Return) ❑Other(explain under-#21 Remarks) 0 .ft. 15 ft, clay/sand
fr... it. •
4.Date Nell(.)Completed: 7-11-23 Well iD#MW-1 . r -ft. • ft.
5a.Well Location: •n. ft.
F rr s,.
Former Wastewater Treatment Plant - ft,- It. -_`L t:�E ii,v SI.s.D
FacilityOwrer Nntuc ' . Facility IDk Of applicable), ft. ft.
AUG 0 7..n123
126' Sunset Drive, Forest City, NC, 28043 . . ' . ft. ft,
. Plnsical Address,City..and Zip <1G REMARKS I T-:,Gzift-
+ rzr`.5., "�.U1t"i 1
Rutherford • I'bentonite seal 3-4ft GlievyL51..Ku p(:aunty rr Parcel ItlenlicdioiNti.(PIN)
.tilt,I;;ttitude anti I.ongituile in degr esfm lsc inutcsconds Or dceitital dcgrrct.: . 22.Certification:-
(itucll t id,ow Limon:i-srJllikru)
l' W .:i — ' _ --_ __' 7/11/2023
Signature of�r v=rr.+„. 9,ti5,,dieci: - Date
6.is(are)the•well(s)r XlPertnanent or l7Temporaey r(: �a r- 7 ,
ilp s:gno,({Air joi,r. rh,!:...:t,,:•, ..,.ra :u;t.:e;ra tzm�rruererl le rcronrair
leiab 15,t NCtC 02C.,1,.,:!.K 1:.i.r i.:A.:::.'C.0200 Weir Como-0e;i ul Srarxtanis and roar a
7.Is this a repair to an cri iting well: JYtu or h No t-apr of this retrial bas trsr,provider?rn ahe in.?'owner.
if this'iv a,t'pa r,fill iMr krraudi n'dl craranrcahxa bgnrrar,:r)on mat(irfrtabt rbe n,arue Of rfie'
r.tnrfarder021 remarks'sit-Tierra or en the bait:of this form 23:She diagram or additional well details:
You(nap_use the back of this page to ptovide"additiottat well site details:or Well
S.Ntnuberof wells constructed: 1 construction details, You may alsei attactuidditionat pages if necessary:
For nrnitiple nfee:I n ar oon-water n,pply melts ONLY midi the some carrs(rimriowt,pan rv,ra •
Sabath ri)m jorr.,. SUBPi1TTAL iNS1fICTIONS
9.Total well depth below land stitfuce: 15 (ff.) 2-0a. For All Welts: Submit this fonu within 3U.days'of.completion of well
For irrrdriple (ft rail depths i/dlfirrnr icrampte-8@21D'and.20!OtT} ' ' ' ' -consIn,ction to the Coitoning:
•
ltl.Static water level below top of easing: ((l) Division of`Pater RespureeS,lnformatian Processing Unit,
if cake heel is above cios(rr;,SIP.'"4-" - 1617 Malt Service Center,Ralci, t,NC 27699-1617
11.liartltntc diameter:8,25' (in.) 24b;For Injer(ion Willy ONLY: in addition to sending the four to the address in
24a above_also submit a copy of this fonu within 30 days of completion of well
1..,`Nell construction method: NSA - . coltstitictiou to the followine:
(i.c,anger,rota(?.cable,-direct push.etc.} • '
Division of Water Resou roes,!Under-tronitd ftijectio n Conti Ptvgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mali Service i Ci nter.Raleigh,NC 27699-1636
13aw•Ydd(glum) Method of test: 21e.For Water Supply&Injection Weds:
Also submit one copy of this;faint %Tithin 30.days ofcompletionof
Il3h.Disinfection type: Amount: .watt construction to the canary health department of the county where
• constructed.
Farm GW-I Nonh Carolina Dcpanmcm of Enviratutrctn and Natural Resources-Division of Water Rr-utres Revised Atgtnt 1011