GW1--04541_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD Fat Internal Use ONLY:
The fortncan he uwd fie singk or nainpk hells
1,Well Contractor Information:
I4.WATI1*811103
John Eisenman ►ttOM to DtKktP1ION
Well('orarictor Nank ft. R,
ft. ft.
4439
NC Well CotamctorCertification Number j IS.OUTER CASING the could eaoed ee1h1 OR LINER(II rp(rlkah4)
roost i TO nt;N►TTN Tnl(-KNr55 111 N4T►11R1
SAEDACCO tt. II. in.
('e urp:un Hank 1i.INNER CASING OR RING teselieneal elnt/-duel)
MOM TO MA.METER THMKNF» osmium
2.Will Construction Permit ti: 0 ft. 10 ft. 2 W. SCE-40 PVC
list di applirable wrif permit tie.County.Skate,Variance.bpertiar(el..i
-
3.Well 1 sc(check well user: I7
Water Supply VI,CO: Y1VOM 10 DtkMPTra MATstrt le4 TTtK1iNT MATKaIAi. ,
LJ:ignwulmual °)Vlunicipnl,Atbl)C 10 ft. 30 f1. 2 ia. .010 SCH-40 PVC
11Geothenrol(Heatin Cooliii Su lv) °Residential Water Su „ sa
� PP Supply(single)
I I Industria(iComntercial °Residential Water Supply(shared) rMRO To MATERLAl EMIACEMI.VT MFTTIOD&AMOUNT
❑Irrigation 0 ft. 5 n. Portland Pour
Non-Water Supply Well: - —_ -,
R, n.
H Monnonnt; ❑Recovery -
Injection Well: n. ft.
❑AguiferRecharge ❑GroundwaterRentcdiation 19.SANITGRss1.L PACK 01n1410ktRil)
r1OOM rr, In;TIM M. CM P1.1fTM►NTMTTNOn
❑Aquifer Storage and Recover ❑Salinity Barrier 8 ft. 30 n. Sand ill
❑Aquifer Test ❑SIomntiater Drainage I
h. it,
❑E'pcnmcntal Teehoolog ❑Stthsidcn:c Coisml
n ❑Truett A DRILLING LOG(attach additional sheds if oeve,rarn)
❑Grotl(cmwl(Closed Loop) roost To j ar-seRrpnoNI.al.r-h.wwe...wilm.I.np,r.tr.a.,r.,Ft.n
❑Geothemwl(Heatitt'CooliIle Return) °Other(explain under 021 Remarks) 0 ft. 30 ft. sand
ft. n. ",, r.1
4.Date Wdka)Completed: 6-28-24 N ill IDa MW-30 r^ i,-_t1
So.Well Locating: ft. . ft. JtiL 3 ' 2514 +
Hamilton Beach n, i n.
Facilarx_lhncrName Facilm 11)k(if applicable) —. n, n. e •�f+`•-., 'tidal
lrJ�:rs.'. sc
261 Yadkin Rd. , Southern Pines, NC, 28387 in� ft
Plnsscai Address.Cis.and Zip 2i.R[MAi ks
Moore bentonite seal from 5-8'
(C,nu,,,,,.IN Panel Identifkiiiiou No I PINT
Sh.Latitude and l.nngirotk in degreeslminotct/eeeonds or decimal degrees: 22.Certlmcadoe:
(d hell field.one I:u lore r.sot lu:co11
N W' ,.�'r- 7/2/2024
Sigeaare o ff;.^tea couscsi - - - Dow
h.Is(art l the%elks): RIPermanent ur DTemporars o `r'•; !! . rir
M.wgning t6n fotnc ih n....":-. s can t...c,,..rued constructed rn ac ondarwr
with.fA NC.4C 02(-.•;.-.:- T..;/i4A�.:1C.0200 Well Cnnarrwrnon Saut,fard<and that a
7.Is this a repair to an C istiog well: °Yes or END r.:p,of rho rr.and ha,been provided M the torn owner.
11*(1 tie a repair,hll.wt known wet,oiasnw wen snfanm ion awl r rptattt file eerier of the
repair ruder S2i remark.,.,rrtn.n or on the bark of this form. 23.Site diagram or additional well details:
Soo mat use the back of this page to pros ide additional well site details or well
8.Number of wells eo.slrw.ted: 1 construction details. You nos also attach additional pages if necessary
For multiple infection,a a.H,-.,tin,.upph walls ONLY with rite anent eons/maken.vow nit+
xabulr one font. SI IBMtTTAt.INSTUCTION S
9.Total will depth below laud surface 30 (ry,l 24a. For .Ail Wells: Submit this form union :Ili days of completion of well
for muhipir nel!t bur 110 depth,,l,lcfernv rr.awnp(r-tpr?0,0',ow(;tit/00.1 constnnctiof to the follosinng
lit.Static water level below tap of casing: (ft.) Division of Water Resources,Information Processing I.nit.
If water kind n abate tomtit.ale".. 1617 Mail Service Center,Raleigh.N(-27699-1617
I I.Borehole diameter:8.25" (in.) 24b.far Injection Wells ONLY: In addition to sending the form to the address in
24aabuse. also submit a copy of this form within 30 days of completion of hell
12,Nell construction method:NSA connection to the following.
;le aster.rooes.cable.direct push ex.l
Division of Water Resources.Underground injediom Control Program.
FOR WATER SUPPLY WELLS ONLY: lhJi SIAll Son ice Center.Raleigh,NC 276994636
13a Yield(t lout of Opt: 24e.For%aici Supply ti Injection Welts:
Also submit one copy of this form within uu des s of completion of
IJb.Disinfection Is pe: Amunat: well consmrctfon to the counts heahh department of the county where
---- comanictcd
Fenn GW-I Non!'Cambia Department of Ear nmmnrw and Natural Resources-Division of water Resatrc6 Res wed August 1)1 a