GW1--03838_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD 0v For Internal UseONLY:
This formmenu be iced for sinnk ormiiltipk netts `V)
I.Well Contractor Information:
II.WATIIR ZONIS
John Eisenman MOM TO eksenIPilOM
We11 Contractor Name R. h.
ft. H.
4439
NC Welt Contractor Certification Number tS,OUTER CASING(far rued-erred wells)OR LINER(Y likable)
minty t0 DIAMF.Trit TIIICENIMS HATT PRI
SAEDACCO it. fie. to.
4'011T:on Naarc lb.INN[R CASING OR TL'RINGigaet►ernial closed-(aqi) _.-._.
H1I)N_ 10 DIAMETFIt I rill(kSFTS M.5TTRIkl.
2.Well('nnstrvction Permit If: , 0 ft. 15 ft. 2 in SCH-40 PVC
Liu ail applicable writ permits(Le.County.Stair.Variance./*ale t we.) - f
fl. ft. In.
3.Well Cie(check well slit):
17.S('RIttN
WaterSupldh Well: aura ' rO nl.St►'Ttn 1 Still sin. !IMF:VPRS MATIOUsi.
1_1Agtwultural DMunicipal;Public 15 ft. 25 fl. 2 is 030 SCH-40 PVC
I'Geothermal IHeatinglcooling Supply) °Residential Water Supply(single) fie ft. 1 is
I I lndustriatiCotnnlercial °Residential Water Supply!shoed) 1f' rCR011T
PROM TO MATERLM. EMPI.S(F.MENT ME 11100 A AMOCNT
CD Irrigation 0 II. 10 R. Portland Pour
Non-Wafer Su(pih Well: 8. ft.
RManitonn:; ❑Rccovcry .
!ejection Well: ft. ft.
❑Aquifer Recharge °GroundwaterRenicdiation —t4.SANDt.ILt%5 r k(I*.lir aftilerIllet
►MOM 10 stilt Hitl _ EMMA(TMr'T MFTROn
❑Aquifer Storage and Recover ❑Salinity Barrier . 13 ft. 25 Ii. Sand 112
❑Aquifer Test ❑Storlmcatcr Drainage
ft. II
❑Experimental Technology ❑Strbsidcrcc Control
Is.DRILLING LOG(attach additional sheN*if nccc..an i
OGeothennal tC'lused Loop ❑Tracer FROM TO DWS(RIPTI()'S io.r,harder..,wriVnick tyre.wale vire.end
❑GeothemialIHeanng.Coolinp Retumi ❑Other!explain underN21 Remarks) 0 ft. 23 ft. clay/sand r.. _,
`d •.+r
i.Date WeU(a►Completed: 6-12-24 well mrrbfif-1 ft. n. JUN
5a.Well Location: it. ft. r 8 2024
Hicks Site It. it. ICrft9f7itiicg,1
Facrir'OalerName Facility IDl(if applicable) -- soli , n.
160 Styera St., Lewisville, NC, 27023 ft. ft.
Physical Address.City_and Zip • 21.R1-M y Rt:'
Forsyth Bentonite seal from 10-13'
('auM) Paled Idetnificatiun No 'PIN T
Sh.Latitude and L.angirutle in degicesiminatesiseennds or decimal degrees: 22.Certification:
Of well field,Ina:lallorig is Sidficrcial
N W _ - 6/16/2024
Si2nnare of' .S lr v.ae:l;.I-- -- Dole
6.Is tare)the walls): ]0Permanrnt ur :Temliorary 2{,�y; :r,�.fs �
Bi signing this Jrn)wc ¢1 d ..,[h,ri. ..:ts 11. 1 ever't'Yfied In atronianc
with 1 5,4 NCAC 02C.', e—-7.:.:i 1."A� :2C.0200 Well Conatrw-pon Srar)detrds and than a
7.1a this a repair to an existing well: D lies or ifi No copy n(this re.ard11a%beets prwided meth.'nrf owner.
',Alt ti a repair.fill out*wawa well eoNrrri&Yiafl information itn.l r vision,the Iwlriire r,(the
repair under 021 remarks section or tm the bait of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells communed: 1 construction details. You may also attach additional pages if necessary.
For multiple a.tjeerhesi Jr Net-waiter fwppls well:ONLY with the arse eamerwMkm t::a„a.
saloon one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below lard surface 25 (D,) 24a. Fur All Wells: Submit this farm within 30 days of completion of well
For aahfple writs list all depths if di*rem ors e'Pip(e.tl@'200'and 24:r 1001 constniction to the following-
In.Static water level Iwbns oily of UAW (fti Division of Water Resources,Information Prucessing Unit.
1617 Mail Service('eater,Raleigh,N('27699-1617
t I.B,tirholc di.tmcteI':8.25" (in.) lib.For injection Wells ONLY: in addition to sending the fofnl to the address in
24a abo e. also submit a copy of this form within ?0 days of completion of well
12.VSrll e-unstrtnturo method: HSA .onstmction to the following.
n. ..n ;i.r.aar..cable.direct push a_
Division of Water Resources.Underground injectWs Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.'fC 27699.1636
13s Yield Iftlmrl Method set a tie.For Water Supply&injection Wclk:
Also submit one copy of this form ii Ohm 30 days of completion of
13b.Disinfection type: Amount: well construction to the count)• health department of the county-where
constructed
Form C,W-I North Carolina Deportment of Ere aomartu aid Naomi]Resources-Division of Water Rrsouca Res red August it I a