GW1--00810_Well Construction - GW1_20240131

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WELL CONSTRUCTION RECORD FileriraluaeortLv:
'this form can be used for singleor ntaltip)c wets .
1.'Welk Contractor Liforntatiop: I .
-It.WATER-ZONES - .
. John Eisenman • FROM 7o -. distant I)N
Well Contrat1r r Karoo R. ft.. . I i
r--, ft. n:. I. I .
4439A `' R a d r, y
NC Well Catmma6rCenificblionNtrndner a :15£•OUTERCASINGdde-month=rasell`sellsl`.ORLINF.R(ifat (leable):'."._
.FROM 70 .DIAMETER MICKNESS. MATERIAL
sAEaAcco JAN 3 1 2024 .. ft. :. •. It; .I I la.
Comply ;� , p . I6.lNNERCASINGOI.t.TUBING'(si.iibiiiMatct'a►ed-lunp)1'= • '
lnr;,riz:,na..) Prn; z.r Uf9: FROU' 70' DIAMETER tt1iCKIVESS NIATemAL • .
2.Well Construction 1'crniit ti: • Girt;.:; O€, . 0 It.. 10 fi. 2 I 'Ili. SCH40 PVC
List all ap licrifYe veil prnui.t(e.'Camrty..Statr,Variarree.Irferay rt err.)
R. ft. 'in.
• 3.Well.ijsc(cheek well tise); t7:SCREEN. •
Water Supply - • FROM 10 ntAdtErhR , sr.Ors;ii TrneresaSS 1 MATEnrAt.
•DAgIrUltitral f�1s4tinicipol/Ptshlio. 10 .fit:. 25 R. 2 iri 010 SCH40 • ( PVC
it° ft.-, in.
ClGeotlicnual(Hcating,Cooliog Supply) °Residential Water-Supply(single) - I
- ClkndustriallComuntcrcial. • ® tt, ..
Residential Water Supply(shamed) 'tGROUT . -_ - _ " _. : _ - -..... . _ ,.„ -
FRO\I••• 70 3LSTERIAL - EMPLACEMENT METHOD C AMOUNT .
• ❑Itiieatian - 0 ft. 5 •ft. Portland Pour
Non..Vater Supply Well: ,
6lhlonitotin; . . . IJRocove y '. it.•
fit: - 1 •
injection Welt: .fir, It. . I .
DAquifcrRechrarge C3ionndisatetReim:di:Ition . `=t9•SANDit.ItAV LPACKtitlip nticabtet;= -: _-. _
FROM 70 I••:k INTERIM.; • . ESIPI ACESIF_NTMI:rRpf
AAintifer Sforagc ati t Rccnvcty l7Salinity l3amor` 25 R. 8 - ft. Sand #2
ElAquiferTest 135tvmi«ater1}r,titingc rt.:. fit.
17S'ctiincntal Tcchnotokr •OSuhsidcncc Control
'111AMILLI G LOG fatlieh'ad'ditiuiinl ibMS if_nccessarv.
DGtwthennaI(Closed Loop). - . •OTrdcer FROM: •' TO- DESCRIPTION((Abr-hardnc.+,varerncratllm.-rratn Am;real
DGeothemnt[(Malian/Codling an/Codling Retutu).. DOther(explain under 42,1 Retuatt s) o fie. 25 It. clay/sand
rt. . .rt. " I :
4:.DitteWell(s)Completed: 1-3-24 •Well 10#MW-3R.
'n.: rt..
5a.Well Locations .ft. ft..
Mullinix Grocery - - ft; 1ft. -
•Facilil)•,OuncrNantc rri o Facility iDk(if applicable) •n. ft -
3079 NC Hwy 109 North Tro,CCMoa eiaer�, NC, 27371 - .rt. fl. . •
. Pksfcal Ai[dmcss.City.and ip '.21:REMLtRKs . . .
��d4// ' �1 bentonite seal from.5-8ft
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Cktnnly parcellt1Catil`ifatiUUNo,(PIN) '
Sb:i>atifirde'and laingitude in legraes/ininu4ssiseconds Or dceitnal ttegrees: 22:(ieilifcadon
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(ituelt field,oaa;lat,'IoL Is.sirffiekmtl) I
N . R I' —.-' 1/8/2024
$igmtueCaf:.y-c.?a Piro,Yra:r ^_- L. Date
6.Is(are)the well(s): 34Pennanent 'or . DTemporary. - �I t f;, !mac ^a
• It'signh,d 1Fir fotu:- r•,,te!u(r ti...,x•' .„rr w..s t.:r:rl.iwrat'nntrd it mrordanee
lithISANC4G02C-w+--1—1 'i�H t,{C,92ooWellCousrrotionStandarda and ilxr:a
7.Is this a repair to an existing well: 0Yes or No roPY of if rerorif1;4.ken pioiuhyd ro'ihe io li Owner.
if this:lr a repair,fill our ktwimwt teed Oraarltctiwrhm/onntrt:on and r tplahi the artrare of the I •
. repair under021 mnarkixrc{icii or en die halt of tins form. ;23.Site diagram or additional well details:
You may use.EL bath of this page to provide additional well site details or Welt
S.Number of Wells Coot dieted: 1 constmetioiideiairs,'You Isar almiiattach additional pages if ne:essaty.
For mulrlpte lofrct(on or nimi,:rater sitppte'avells ONLI'with the saaie.ciors(rurtlorr,you con
.cn3rnit oar form: - - S Ul3Mi7TAL INSTilCTiONS
9.,Total Well depth beton land 25 - - (ip.) 24a. Fur All Wells: -Submit d4 fuim within 30 days.of.coinpktiOu of well
For mahlpieirreir list'oil 11cprksiifdfi•rent(cramp(.-7 200°and203'10rvt construction toILf Cloning: i -
1.0.Stade water level below trip of easing: ((p.) Dii'ision Of-Water Re-stiurces,Information Prueessing Init; •
i/iiumr ki rl is sGbre cuairPi ru"-r" I617 RLtil Serrice Center,Raleigh,NC-27699-I617
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I I.Borehole diameter:6• (ia.) .24b.Fur inh ctinn Wells ONLY:I hi addition to sending-IL toms to the address in
• 24a ab0e, also.s mbntit a copy of this within 30-days-of completion of well
12.Well ctnstruction method:Air . . construction to the following.'
(ie.au .r.ropy,'Cable:,direct posh.etc:) • .. r ' . . .
Divisitut of�Vater:Resourcest Underground Injeetion.Control Prog ant,
1636 Mall Set•Vice Center.Raleigh.N 227699-1636
FOR WATER SUPPLY�i'ELLS'QNH.Yci,h� C
.24c.For Water Sutiply&i Iniecttnn Wells:
13a.Yicl i(gpm) ,Mettiod'of test: •
Also subunit one copy of this faint I Within 30-days.ofeompletiott of
131r.Disinfection type: Amount: well construction to the-county health department of the county where•
constructed.
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Form OW-I NonliCamlinaU^panment.ofEtndroureett•and•yanmral Resources-DiviclouofWoicrFt otrae5 Revised August 10l3
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