GW1--05169_Well Construction - GW1_20230818

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WELL CONSTRUCTION RECORD Far Internal Use ONLY:
tit form can be used fin single ormultipk wells• .
1.Well Contractor information:
l.l.WAr1!R.ZONES
John Eisenman FROM TO DESCRIPTION
Well Col:tractor Nanie rt. R.
fL ft.
4439 •
NC Well Contractor Certification Niurilcr IS.OUTER CASING rtitutll-eased Wells)OR L11'IL'R Waiffieahlel.
FROM TO DIAMETER THICKNESS MATERIAL
SAEDACCO (L rt. in:
Caine ury Kam - I6.7NNER CASING OR"T RING-(yeatrermal dused.lonir)
FROM TO DIAMETER THICKNESS 1 MATERIAL
2.Well Cbnstr'uction Permit>r: • o ft. 23 ft. 2 hi. SCH-40 • PVC
List all applicable well pennies(ix.Counrt•,.Stair.,.i°nonce.Injection err.)
. R. ft. ia,•
3.WellUse(check well use): ITCSCREEN -
Water Bullet.Well:_ - - - -- FROM 10 DttMETliR SI,OTSI71 THICK N iS 1 MATERIAL
❑AgriCillturnl ClMunicipal/Pliblic 23 .010 SCH-40 PVC ft. 33 ft. . 2 in..
❑ rm Geotheal(NeatingiCooliug Supply) ®Residential Water Supply(single) rt. ft. in,
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DlndustrialiCommercial ®Residential Supply shared) - OCR OUT TO MATERIAL EN[PLACE\rENThtEIr14H&AlVI0uNT
Dirrigation 0 • ft. 19 ft. Portland Poui
Non-Water Supply Well: '
R. ft.
®h40nitoring DRecosety ft. ft •
Injection Well:- -
D Aquifer Recharge DGronndwater Retacdiation 19.SAND/GRAVEL PACK iif applicable)"
FROM TO MATERIAL EMPLACEMENT MI7HOR
DAquifer Storage and Rcetmlciy DSalinity Raider 21 ft. 33 ft, Sand #2
['Aquifer Test ❑Slonnwi to O ninagc
R. ft: •
❑Experimental Technology DSilbsidcm c Control
•20.DRILL111G'LOG(attach additional.sheets if'nccesmrvl
OGothemial(Closed Loop) ❑Tracer FROM TO DESCRIPTION robr.Itaniiei,soIlr+scklvot.satinvie.del
❑Geotitennal(FIeatii,a Cooling Return) . ❑OAier(explain under#21 Remarks) 0 ft: 33 • ft., Silt/sand/clay
ft. • ft.
4.Date Well(s)Completed: 7-5-23 Well MUM-8 'ft. ft.
Sit.Well Lecatinn: ft. ft. t.: F C E �l
Former Cleveland Mills ft. rt. rc
FaciliiyiOwnerNanre Facility lDk(ifajtplicable)
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R. ft. Yt7U ! O pmQ 2023
R^u
101 W. Main St.,.Lawndale, NC, 28090 . ft,. rt.• .
inft'rfiTali^n °Dana
Plnsical rtddress.City.and Zip -21:REMARKS r� •a. -"8 r'`-?V�1
re t•e'L!t-s;
Cleveland 19-21' bentonite seal }'°f`'�'"
County Parcel IderiGricallon No,(PiN)
5b.I:iltitude and Longitude in degreeslminutes/seconds or decimal degrees: 22.Certification:
(Knell field,else laSbug is sufficient)
N W ., „ -- '`- ----_--- -- 7/7/2023
Siotuturl:of '^7 h'•. .:1r�•urdm-^:ti.c ---' Dale
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6.Is(are)thewell(s): ZtPermanent or_ ❑Temporai}' � real !. , ,,fs ,r,¢a �a
Il signaia their four:- nth•. 'x: 4d,was r.:e.r,.eta emceed in a c'ortaice
with 15ANCSCO2C177 C.0200MUCrmsrrrcriwrSrandarclswidibara
7.Is this a repair to an existing Sti ell: :]Yew or KIND copy ofdiii record bits been provided re?fiki tirll morer.
If tbrs"Iso rep t*.fill our Rrvu4r idleatu-trr e,ion irrforrrutrlwr d na,explain the rutrare°Idle "
rrpoirtenler t2I reolorkserctian or on the btnk of this'form. 23.Site diagram or additional well details:
'(co may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 cousliuctioii details. You may also attach additional pages if necessary.
For trralalplc:l'idectlon-ormon-ivarer supply n'etls ONLY with the sane constriwllon,}+°a can -
sabmir one fong. SUBMITTAL INSTUCTIONS
9.Total well depth below.land surface: 33 (ft) 24a.m Fru-All Wells: Sahmit this font within 30 days of completion of well.
For tnrrhiplewells list all depths If different(c.raoipfe 3€209'and 2@NA1') conslmction to the tonozsing;
10.Static water level below top of casing: (R,) Division of Water Resources,Information Processing Unit,
1f uvster lrge!1s above cask;.use"+" 1617 Mail Service tenter,Raleigh,NC 27699-1617
11.Borehole diameter:8.25" - (m) 24b.For fntectigr}Wells 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 construction method:HSA - cousimetimt to the following: •
(La.auger.rattly,cable.direct lash.c[c.} Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gem) Method of test: 24e•For Water Supply&injection'Wells:
Also submit one copy of this form within 30 days of completion of •
13h.Disinfection type: Amount: well construction to the county health department of the county where
- constructed. 1
Farm GW-L Nanh Carolina Department of Ern iroruo,u and Natural Resources-Divrlon of Wales Rmoutm Revised August 2013