GW1--01430_Well Construction - GW1_20240301

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WELL CONSTRUCTION RECORD Far ltvnudusc.ONLY: I
This fartncan be used for.single or multiple wells•
1.Well Contractor Information:
"4.%VATIER ZONES
John Eisenman .. .. .. . FROM TO - , DEtS(RIPIIONi
Well Contractor Nemc R, ft, I
4439 ft. ft.
NC 1Vc11 ConlmclorCcnifi®liori Nwiiicl IS.OUTEti CASING(tor realer ca ed ectls)`OR LINER(if uii flcabk)
. FROM TO • " DIAMETER, . TIIICKNr.SS• MArtflt%t.
SAEDACCO ft. ft. lu.
Company Nam MANNER CASING OR TUBING.(geolbeemal erased-loop):•'
FROST TO DL4.11ETER THICKNESS MATERIAL
2.Well Construction Permit 8: 0 ft. '5 . ft 2 itti. scB-40 PVC
fie uli apgrli ukre weir permit.'fie.County.Slam,Variance.lnfit-044 etc.) R. ft. ltna
3,Wclt.Use(check Well use): it.'SCREEN
Water Supply Well:
--.-- - trtrom TO .DIAMETER StOTSID: TittcrO ttS I MATERIAL
ClAgticultutal oMunicipal/Pttb)ic 5 ft. 20 ft. 2 in 010 SCH-90 PVC •
❑Geotheimal(HeatinglCooling Supply} ❑Residential Water Supply(single) ft. ft. in
❑Ilidustria1lContutercial ®Residential Water Supply'(shared) OP
GROUT TO " • 1IdTERIAL • E\tPLACE\SENT\fEr110D SAMOUNT
❑Ittipation 0 ft. 3 •ft. Portland pump
Non-Water Supply Welt:
R. • ft
• ®Monitoring . pRccoyrp' . . .
• In.Jecllon%Yell: ft,• • . - ft. . . . .
°Aquilcr Recharge" DGioundwater Rentcdiation :i9:SANf/GRAVEL PACK'Of,ytplieabtel:-- - - - -
`FItOM • - TO - 'MATERIAL •• EsIPLtCt IP_NT5n7n0n
l7Agai(cr.Storagc and Rccolety i7Salinity Barrier. 4 ft. 20 ft. Sand #2
❑AgnifcrTesl orinw tcrl nttnage R. fL.
17EVerimcntal Technotogp ❑Subsidence Control. . ...•
••2f1DRILLING LOG knack additional slicetslf necessary'
' DGeotliczwaL(Closed Loop) _ :.❑Tracer" .FROM ' TO DESCRIPTION raobr.rmmnn.utiTntck firm,grain sto.dr-t
❑Geodtermal(lleatiog+Cooliue Return) ❑Other(etplain,lntder li21 Rettiat s) 0 (L 10 ft sand
10 f. 20 ft. clay ,
-I.Date Well(s)Completed; 1-23-24 .Well ID#P-2 . - _
.fL. P-+. Vie-..M.-.of.I r . T..�.
So.Well Lut:ation: • I •' f \L-`A L i Sl! E"�,,,;
, ft f4
Sampson County. Landfill f.' ft, I , MAR O. 1 2024
FacflityibsrorNanie ' Facility 1Dk(ifapplieablc) R. R.
7434.Roseboro Hwy,.Roseboro, NC, 28382 R, it. ittt@rPt..i. .ita ,' ,"•.'sr'.''"'4 t✓YI),
DWO/ OG
Physicnt Address City.and Zip• '.2 L R.EN.L\ki{s
Sampson bentonite seal from 3-4ft
Gouuty Parcel I ntificaalion No,(PIN} '
Sb.l htifitde and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ccrtifcation: I; •
(if ci clt field,au lasloug Is stdttekrd) -
N • W ' .fir {-----' - --_ 1/28/2024
Silmwse e 1.::. lirimrhoes, • _ Date
6.Is(ire)the wells}: ItIPcrmaitcnt or ❑Temporary y signing Mir
fen 1.FP,4:1.6,1k;:if..„dux s cc1 i y. cowman!by necanhroce
with 15A iVCAC 02C.'x-+^-',�=t,•:feet CFIC.02001t F Counrrurrfar Standards and t+ear a
7.Ls this a repair taan existing well: lJYes or 79No copy of this record hastaertprovidcdra Jae urliowner,
ifrh(sYs a rep sfr,fill fit karma well canslntctfotr information and rap?aln the narare of-rhe
repair ardor 0')zrmurL section or on the bail of this form. 23.Site.diagram or additional will'details;
You may use the back of Ibis page to provide additional well site.details or Welt
8.Number of wells constructed: 1 cousttucti.on details. You may alto atlacttaddilional pages if necessary.
For nth*lrtfecrlmi or,soar-mtrer supply wells ONLY with the some construeIIon,you eijo
sabutirrne form. SUBMITTAL.INST(ICTIONS , ,
9.Total well depth below land surface: 20 (ft,) 21a. Fur All Wells: •Submit this font.within 30-days of completion of well
Fern,itiplewellslisraIferprhsifclVivent(example-3@2P0'oral2@100) Con$tnictipnto the following: , •
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10.Static water level below top of casing:na (pp,) Division of Water Resources,Information Processing Unit,
. If water level is above easing.trse"+" 1617 Mail Service Center,Raleigh,,NC 27699-I617
11.Borehole diameter:8.25" (111) 2.1b.For fit 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 compietian of well
12.Well coustniction method:BSA consimetion to the following: •
r ear -
(i.e.augens,cable direct posit cle.} i I
Division of Water Resources;Underground Injection.Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Cent I r,Raleigh,NC 27699-1636
13:I Yield(gpm) 24e.•For Water Supply&InjectiunFWells:
Witold of Also suhink one copy of this RIM' Within 30.days ofcotnpletioitof -
13b.Disinfection type Amount: well construction to the county ltcalthi depanment of the county.where
constnicted.
Farm Gw-L Wool:Carolina Gpmntrru of Emmtt tinrm and Natural Resources-Division of Water R of Revised August 2tt 13
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