GW1--05163_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORD For[menial use ONLY: .
This form an bo used for single or multiple wells I
1.Well Contractor Information: •
:I I.WATI!R:ZONES '
John Eisenman FROM TO Dt=SCruPrIOY •
Well ConIr ctor Name ft. ft. F '
4439 ft. ft.
NC Well Contractor Cal ificntianNiuthcr • I .OUTER CASING LINER Ufi gkabkl'.
.FROM TO DIAMETER THICKNESS MATERIAL
SAEDACCO rt. it.. In.
Company Name 16.INNERCASiNG OATUBINGt1leoirermal ckusedaoup) •
FROM 70 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 R. r 25 It, 2 ill. SCH-40 PVC
Lin alt ojpalicablc well(anvils(ct!.County.Stole,arian=Walk";tic.) R. R [14
•
3,Well Use(check Well use): 17.SCREEN
• ---Witter Supply Well: . TO - DIAMMETIIR SKIT SIZE T111(1iNI S I MATERIAL,
• - FROM
❑Agricultu at • •DMunicipaUPubliC 25 ft. 35 R. 2 in• 010 SCH-40 PVC
❑Geothermal(Heating/Cooling Supply) C°Residential Water Supply(single) fL' ft in,
©htdustrial/Conuncrcial ❑Residential Water Supply(shared) :Om°UT To MATERIAL CA[pLACEHEVT5fEi110D R'AUOt1NT
❑Itripation - 0 It, 21 f_t. Portland • Pour
Non-Water Supply Well: •
IDMonitoring fRccovely R. ft. 1
Injection Well: - - - - .ft. fr.
°Aquifer Recharge DGroundwatcr Remcdi;Rion •15.SANDiGILILVEL PACK(if applicableY:
FROM Tyr MATERIAL. E5IPI A(: IE TMrrti011
❑Aquifer Storage and Recovery DSalinityBaiiier 23 ft. 35 ft. ' Sand #2
❑AgnifcrTest . • ❑StommatcrDrtinagc iL ft.
❑Experimental Technology .❑Subsidence Control
. 2or'DRILLING LOG(nllactt additional skits-if'acecssan.l
❑Geotltemtal(Closed Loop) ❑Tracer . I'ItOM TO DESCRIPTION f cob r.Imrdne,i,wtunk&iv nu itin,ve.tic.)
❑Geothennal(Heating/CooliueReturn) . ❑Other(explain under A2IReivaths) p 0 ft, 35 It. Silt/sand/clay
ft. - It.
4.Date Weil(s)Convicted: 7-5-23 -Well MAIM-7 - • ft. rt. r--
54,Writ Location: ft. ft. i �� R�'L L._ /
Former Cleveland Mills ft. ft.
Ra
_ ib,o
Facility,OnncrNatae Facr7ityIDt(if applicable) R. R. c6—:p1-8�°CJ
101 W. Main St., Lawndale, NC, 28090 ,
Physical Address.City.and Zip =:2I.REMARKS DV-i l.`?,CA 2 a'R
Cleveland • 1 21-23' bentonite seal _
:
Calmly Parcel identifaeniiou No,(PIN)
5b,Latitude and Longitude in dcgtces/minutes/seconds or decimal degrees: 22,Certification:• -
(tJ'seu riclrl,ono httlougis sidliclenp
N W i s� _.-_--- --- 7/7/2023
_,,,c —
nrw Sigre of ��:?:t; 7,t,r� , -- -_ — Dale
6.Is(are)the well(s): $iPennanent or.- ❑Temporary INsigntii is fira,r {:AFZ" iA••f{'etc i1 rti•..•l 1 stir+u'rnrc'fcd in cccorrlmanr
with 15,4 NCAC 02C.';r::',-r-1.:..:,CAS d C•0209 Well Caarstrnctian'Standards crud alaro a
7.Is this a repair to an existing well: ❑Yt s or END cqu of this rceoni hIs&.-ra provided to die m*11 mutter,
if this is a repair.fall rat hrioiava ticil c'oau-1iarctlon lit/orrnerlwt m tl exi ohr the,Iaezre of the
repair rtmler k21 remtrk's.irctia n or on the braaI of this:form. - 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 coustiuction details. You may also attach additional pages if necessary.
For multiple mofeetlon or arm-water supply wells ONLY with the same coarstiunion,Oa cao
sabnrit one form. • - St1BI1MITTAL iNSTiTCTIONS
9.Total well depdt'betaw land surface: 35 (n,) 24a. Fur All Wells: Submit,This,form within 30 days of completion of well
For multiple weds list of depths fldlfeosis(c•.ramok-J€:Pta•and 2@too) con5tnictipntodiefolloning;
10.Static water level below top of casing: - (ft.) Division of Water Resources,Information Processing Unit,
ifmita bevel 1,above cvasba,;,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
•
11.Borehole diameter:8.25" On.) 24b.for>fnjec(ion)Vells.ONLY: ,In addition to sending the form to the address in
24a above,also submit a copy of this form within 30 days'of completion of well
12.Well constntetioll method: RSA constmetion to the following:
(i.e.auger.rotary,cable.direct push.etc:)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I636 Mail Service Center,Raleigh,NC 27699-1636 •
13;! Yield WO Method of test: 24e,For Water Supply tic Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Disinfection type: Amount: well conskniction to the county hcnith department of the county where
constructed.
Form GW-1 Non h Carolina Depaament of Environment and Natural Re93nreCS-Divir ion of Water Resoiras RevisedAugust20I:I