GW1--01433_Well Construction - GW1_20240301

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WELL CONSTRUCTION RECORD
Far tteeriiao use ONLY:
This formica be used for single or multiple wells .
1.Well Contractor inforuation:
'.14:WATER ZONE • '
John.Eisenman . . . . . FROM TO ' DFS('RIPtiON1 '
Well Co tractorNanW ft. R, I I .
4439 • ft. ft. 1 ;
:'tS:OUTER.CASING ffor uttll-riselirstis)OR LUNER(tfap fflcabk): -
NC Well Contractor Certification Monts ,
FROM .TO DIAMETER', TRICKNESS• MATERIAL
SAEDACCO ft.• ft. - 'le.
Con uty Nome ' • I6:INNER CASING'OR TUBING(teatbcrmal eftscd-loop)r-'
FROM TO DLLIETER. TiUCKNES9 MATERIAL
2,Well COPUTtIetion Pct•mit i#: 0 ft, 25 . ft, 2 1.4 sCH-40 PVC
List all applicable welt primits(cc.'Cammw.Slatc..lrrinkurrr,Infecting Jr)r . .ft i In..,.
3.We se(cheep.wel moll 17. ( 1I
-Water Supply Well: _.._ FROM . TO •wastETER BLOT SIBL IMMO O..S HATERtat,
❑Ag[icultutal ❑j� di 25 ft. 35 ft. 2 is .010 SCB-40� PVC
pallPttil)ic
❑ nGeothei at(HeatingiCooliog Supply} ❑Residential Water Supply(single) ft. fL in.
©Industrial/Commtercial ®Residential Water Supply{slid tent) 'ts:GROUT. . ._ •_ . -
FRO�I TO •MA'lER[AL EMPLACE\SG1ThiEi110DS2A5fO0NT
❑Irtipation , 0 ft. '19 •ft, Portland pump •
Non-Water Supply Well:
R. ft
183.1%foniloring pRccoasty.
injection Welt:. ft. O.
El Aquifer Recharge OGrOund43aterRcatediation- 't9:SANDIGRAVEL:PACK(ifapplicable)" •
mom - " TO' 'IIYIFRIAI -• EMPLACEMENT METHOD • '
PAnnifcLStomgc and Rccovcty ElSalinity Hamer 22 ft. 35 ft, Sand , #2
• ❑rlgsiifcrTest l 1Stonmaater Drtirmgc
. ft. ft.. •
OLxperimcntal Technology . • ❑Snbsidcncc Control -
2R;DRR.LTNG LOG(attach additional ihcefs ifnccessan•t
❑Geothermal(Clased Loop) C1Tracer .FROM TO DESCRIPTION tmbr.hsNnct,s.d4rnck*Yne:xrstn sile.Nat
❑Geothermal(Ileatine1Cooliva Retur)) ❑Other(explain tinder#421 Retnaiks) 0 ..ft,, 30 ft, sand
30 ft. 35 ft. clay _
4.Date W.etl(s)Completed: 1-23-24 Well lNi P-3 ft. it •° ^' 7..-t Q r "�
1.
Sit Well Location: ft• . ft. ry
Sampson County. Landfill ft. it MAR 0 1 ZOL4
Factlit}•,+OirncrNamc, Facility TDk(ifapplrable) _ _ - ' . , - -
. ft. ft, ft-iforrnatten Pr:.,:6,$)::7,UFO
7434 Roseboro Hwy,.Roseboro, NC,.28382 ft, ft. DWWQi5t)Li
Plrysical Addles.City.:and Zip' '21;iIENIARKS
Sampson bentonite seal from 19-22ft
Omuta• Inner Id iiliftciiion No,(PIN)
Sh.l.ittinidc and Longitude in degrceilminutes/sccdnds or decimal degrees
22.Ccrdit dam:
(If toil field,one 4a51oug is$ttf1ick.id) j •
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N W1!• 7----- 1/28/2024
Signatutea r.'s ;;a ..9r i.,:,�r;is - Date
6.Is(are)the lell(S): $IPennanent .or ❑Tcmporary '''� ;?r'(-ft/ •OM: �!� i
.signing Ibis fame. S.u(.. X:Mtydl w.er s..etr)eungractrd he amorrlqum
with 15A NC.IC OW.' 9-=1�,.;ICA:.:ZC.0200 Wd1 Co rstrrtiar Standards and that a
7.Is this a repair to an existing well: ElYes or ISNo ropy oftitit rcconf his bcrn provided to the sir11 owner.
If tis'Is a n'pair;fill oat knoasi weld o msintellaa hrforrauulon and expfabr the nature of the
repair amrferr#21 arum rkv seciidn or ova the brisk of this form. 23.Site diagram or additional well details:
You may use the hack of this page to,pros'ide additional well-site details or.well
S.Number of wells constructed: 1 • consnueton details. You May also attach Additional pages if necessary.
Far mnitlple lcifecrlon or non-water iappli•well ONLY with the same cottsrractdon,you can
• submir'ane form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 35 (ft.) 24a. (uur All Wellst Submit this form within 30 days of outpletion of well
'For mufrlplr wells list all depths ifdift-erent(example-3@200'and 2@WO) construction to the following: -
10.Static water level below top of casing:na at) Division of Water Resources,Information Processing Unit,
If moo level is above costal?:use"+" 1617 Mail Service Ccntcr,Raleigh,NC 27699-I617
tt.Borehole diameter,8.25" -(in,) 21b.For infection Wells ONLY: 1iin(addition to sending the form to the address in
24a above.also submit a copy of this fonn within 30 days of completion of well
12.Well coustiitction Method:HSA cotutmction to the following: .1
(i.e.anger.rofal},rabic,direct gush eta) 'Division of Water Resources,Under ground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: s 1636 Mall Service Ccotcr.Raleigh,NC 27699-1636
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13a Yield(>pm) hleHtod of test: 24c.-For Water Supply.St inieetioa Wells:.• Also submit one copy of this fortis within 30 days ofcompletionof
13b.Disinfection type Amount: well construction to the county health department of the.counl.,.where
constntcted.
Form G1tr-t North Carolina Department of Environment and Natural Resources-Division of Water Rmtoti ei Revised August 2013