GW1--04634_Well Construction - GW1_20240809

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WELL CONSTRUCTION RECORD
�\%4 For Internal Use ONLY:
Des Forman'be used fix cinek or multiple++ells
1.Well Contractor Information: \
14,MAERR ZONIS
John Eisenman MOM TO uF'sl krPI ION
WcIl contractor Nanw ft. ft. '
4439 ft, It - - --
NC Well Contractor Certification Number IS.OUTER CASING(for mold-eased sirMsl OR LINER 4W innNesbit
___
mom I TO DtO4 tFR uilc 'crNs Il MATERIAL
SAEDACCO It. i Ii. in.
('orlipsu)Nang .14 INNEN CASING OR TL'RING(yleabermal closed-Iut.pi
MOM - TO DHMF1f5 out hag s' NIcIF WI U__ —
2.Well Construction Permit t: 0 ft. 35 ft. 2 SCH-40 , PVC
List all appli.nble xell pennies fie.Crmnty.Swsr.Varian-..flagon err.! R.
in.
3.Well Cie(Check well awl: 17.WHIN
W'aterSuppli Will: MOM TO DLAMVTY.R 'Opt'Vl ttin l v,+ NI1Il k1 u.
❑Agricultural L IMunicipalrPubiic 35 R. 50 ft. 2 is .010 sex 4o PVC
❑Geothermal(Heatingcooling Supply I(Residential Water Supply(single) ft ft. is
I Ilndustrial/Comrnercial I.IResidcntial Water Supply(sl>~ired1 IR GROG •
MOM TO ^
MATERIAL __ i+IN +.I sit\I NI I491,A .Nutt+l
❑Irri@atron 0 ft. 30 ft. Portland Pour
Non-Water Supply Well: /t. ft. , -
NIMonitonne ❑Recosen
Injection Well: h. fL
Li Aquifer Recharge ❑Groundwater Remcdiaiion 19.SAND/GRAVEL PACK flf applicable)
FROM TO S uI"nlit. rM P1A('Y,N[VT TATTOO!
°Aquifer Storage and Rccoten' ❑Salinit Barrier 33 ft. 50 A. + Sand #2
ICI Aquifer Test ❑Sionmsatcr Drainage t
ft. ft.
❑l;perimcntal Technology ❑Sidsidcnuc('ntrml
20.DRILLING LOG(attach additional ibeets if oecessari l
❑Geothemial(Closed Loup) ❑Tracer MOM TO DP.YCRIPT1OSIt,M'.u,nise..wienl.rt Pr.Ink ar..+r.I
❑Geothemwl(Hcauna+Cuolittg Retool ❑Other(explain under li-'1 Remarks) IL rt.
R. n. _ - .._ -.
4.Date W'ell(at Completed: 7-8-24 Weil MsMK-1 `i c.,1.a...• •l ,,)
R. R. / l.. r
Sa.Well Location` ft. rt. AUG aJ 9 2024
Lamont Fry Property It. fr.
Factlm CtasncrNam Facflip IDN(if applicable) — ft. ft. i lrfb:AW.t'.►r. I.--r•a„..' a lilli
5737 OS Hwy 1, Vass, NC, 28387 ft. ft.
Ptns+cal,Address.CM.and Zip 2I.REM'RKS ' -
Moore ' bentonite seal from 30-33ft
Coasts perrcl Idcnniklmn,n N❑ (PIN
Sb.Latitude and Longitude in dcgittslminutesheennds nr decimal degrees: 22.('crtifiratiDi:
(ltweil field.One I:r.1ogg ix%unicicnl I
N W' '�-- 7/17/2024
Signature of:' ' ':flCI,..saes s- - D,nhc
1- ��� .
n.I.taredthesscll(rl: XPennanent or _Temporary G ;;re°'nTr. fhyr�q rya. t
ti signing tits finny lh ti.... rx 4 :I is w:La i.:e, lYMrouried In IXY'Otaldrt[E
with I NA NCAC 02C A:.71C.Omit Weil Cooutrrrfiwl SwtSards and that a
7.Ls this a repair to an existing well: D lira or R No roc,-of Ail roe ord has berm provided To:i nvU ni.•ner.
Ifthls 1r n rtparr,fill.Ntf meat cell c mount nos mf'rrnurnm nod rtplast t.e wiper of Po
repair tinderS2I remtark...rrrtion or ua rhr buck of rbi..form. 23.Site diagram or additional well details:
You may use the back of this page to pros Kee additional well site details or well
8.Number of wells cotmitrwYed: 1 construction details. You rimy also attach additional pages if necessary.
For.nulliple tnjectitrn<n nwl-nvar.,uppl.a.'l,ONLY n ill Mr iSlwt CiMgrIW NI •.,,li i<m
tatutiirone form. SUBMITTAL INSTUCTIONS
9.Total well depth below laud surface: 50 au 24a. For All Wells: Submit this form within 10 does of completion of well
For nraltiplr.AYI&lisl.r(l depths'if different le'tim.p(r-tE`201Y anti:9l too consinictian to the folklwine
10.Static water level below top of casing: (fl.l Division of Water Resources,Information Processing Unit.
If woke lrtrl n idore,n.v,: - 1617 Mail Service(enter,Raleigh,N(-27699-1617
l I.Borehole diameter.8.25" (lout 24b.For Inkxdon Welly ONLY: hi addition to sending the form to the address Hi
24aabone. also submit a copy of this form within .i.O dins of completion of well
12.Well conitnictiun method: NSA constitution to the following.
tie.atpet roan.cable.dirccl posh.clef
Whim of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY'WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 2'l/'i-1 a36
13a Yield igloo) Milton!,if n'.1: 24e.Fur Water Supp11 A.Injection Wells:
Also submit one cops of this Intro uilhm ;u dossof completion of
lilt.Disinfection type. \uI IInI: well construction to the count health depmment of the count}where
constructed
Form 6W-I Non!'Catalina LAqunneni of Ens iraiint ul and Natural Resoolr:e1:-Div(vies of Wan Resources 110 dud August 2013