GW1--03625_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD ��"\ For Ink,n.,l C c ONLY
This form can tic used for singk or nwltipk wells 1.
1.Well Contractor Information: \\�
14.WATLR ZONtS
John Eisenman /ROM To DEM RIPTION
Well('omlr oot N.mme; ft. ft
ft. n.
4439
N( Ne13 Contractor C cnils.ilmon Nrmntbcr 15.OUTER CASING(far multi-cared netts)OR I 'tR Of able)
rpom To DIs\IT'rFII r Ttii1 k`\WSS MATTRtAI.
SAEDACCO ft. ft. o
(a a gran N:nn 16..INNER CASING OR TUBING tvs+Ihermai ctrseddno )
room t To ' DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 R. 40 ft. 2 s . SCH-40 PVC
List all applm.able 1.41 permit,(i-r.Cower.Starr.Variance.Irtirfiort me., m - -
fl. ft. in.
3.N (check
'ell Use(chk well uses: 17 SOWN _----- - ,
PR
Water Supply ell: OM to DtASITTf.R ' S1.0 u slit 11111 .10 I , sl%I F NI u I_IAgnc:uhural LIMtmicipalrPublic 40 R. 45 ft. - 2 lcO10 SCH-40 PVC
UGeothennal(HeatingrCooling Suppl)l I 1Residential Water Suppl (singlet ft. ft. - ia.
[lIndustrial/Commercial 1(Residential Water Supph (shared) 1�.tCROUT
(ROM TO MATERIAL EMPL(CE/4E a METHOD t AMOGNT
❑hmgation 0 fL 35 U. Portland tremie
Non-Water Supply Well:
ft. ft.
ElMoutonni ❑Recotien
Injection Well: a ft.
---m
OAquifer Recharge CICimundnatcr Rcnlcdr:,inn It.SAN r WEL PACK(tf I, kale)
Fn11M EMMEN %I%It HI%t. EML'1.4r rMr5T MiTNOn
OAguifer Storage and Recover) ❑Salinity Hamer -38 ft. 45 ft. Sand 82
DAquifer Test ❑Stonmsater Drainage ft. ft, i
OENIpennienral Technology ❑Subsidence Control — I
2n.DRILLING LOG(attach additional sheets If necetrsan)
OGeothennal(Closed Loop) ❑f racer room ' To 0F'5f511TION i,shr,ho dsw..,N.ii n..I.n pr.men vr.tot l
OGeothermal tHcatingtC'ooting Retumt ❑Other(explain under a21 Remarks) 0 ft 45 it, sand
ft. ft.4.Date Well(s)Completed: 5-24-24 Well IDr1MW-6
h. 4.
Sa.Nell Location: ft, ft, '.'• s 1. f T •
Williford Cleaners U. ft. 1 ,`
FacmIns-th•r,er\law, Focht'''. ID%(ifapplmca J
blc) ft.. UN 1 3 2024
108 Sterlingworth St., Windsor, NC, 27893 ft. ft. (TIeOtRiuff!'l1 Prpf Y4 *
Pits steal address.CM.and Zip 2L R[M -
Bertie Bentonite seal 35-38'
(..,,u,n Parcel ldenldla how No (PIN)
th.Latitude and Longitude in Aegices.mitmecs.sccnnda or decimal degrees: 22.Certification:
ul u..li Is lei •11.2 tat I.,i y Is mai.:r.,til,
N W � - 6/3/2024
Signalise of :, ."6 y. cti - _ - Dale
6.b tare)the%elks): %IPermancnt or 7Temporary aI) ,ram. �s�p.A�c■-mot
M rgniag this ferny Ittly 0..r_:4 47.: m.:r:el zan%t»rrted in accordance.
with 1 SA NCAC 02C.;r-. rT,�,.CA..;;IC.0200 Well Couurrw don Standards and that a
7.b this a repair to an existing well: ❑Yes or IONo corn nfMit reran(has hem provided se the well owner.
If this as a,%parr fill oat&m ann kell a01,a t h on information and rrplam thy*nave of rhr
repair order I2!remarks%Celia,.or an the bark of this form. 23.Site diagram or additional well details:
Yolk titan use the back of this page to preside additional well site details or well
S.Number of web canonic-ad: 1 construction details. You ma)also attach additional pages if necessan.
For mtdnple anjeraon Or non-ware, .sr,d. ..rl7,(rhll ..,p,Ow tame a imnttrhrnnn ran,an
sabanet,ow form. SIIBMITTAL INSTUCTIONS
9.Total well depth bekm land surface. 45 (ry,) 24a. For Al Well": Submit this font) auhut Ill days of completion of well
For maim*arils hit a0 drprlti if dr$rrent te•xt.nrot,- on'is. ,.,s7,,..f.Y;, constriction to the following
14.Static water kid below top of casing: ffLl On linen of Water Resources.Information Processing 1 nit.
It..otr,lrtrl n a1a•.r.a.,o. „.• . 1617 Mail Service Center,Raleigh.N('27699-1617
I I.Borehole diameter:8.25" On.) 24b.For Injection Wells ONLY: hi addition to sending the form to the address in
24a abos e. also submit a copy of this form within 30 days of completion of well
12.Well construction method: NSA :oustnlctlon to the folloss Mg.
ti c.auger.(Nan.cable-direst posh.etc t
Oh him,of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY.: 1636 Mail Service Center.Raleigh.NC 27699-I636
13a Yield trim) AlrtiFnd of test: 24e.For Water Suppls &Injection Wells:
Also submit one cop) of this form within 10 days of completion of
131)_Disinfection type: Suwon): well construction to the cotton health department of the counts where
constructed
Fenn GW-1 North Carolina De/Jammu of Ens ooruuumu.sad Natural Resources-Dineen of Water Rtsouea k,:s tsed August'r)I