GW1--04681_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD For live ma:l.'s,:ONI ti
Thts form can ts;owe for cingk or moltipk..Ci15 \5 (e
I.Well Contractor Information
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I14.WATER ZONES
John Eiseman /ICON tO , DEM Rtnu)v _ ,
Well('orerletnt Name R• R.
f, ft.
4439
NC Well ComrtklorCcnificalion Nuni+cr i 15,OUTER CASING tier eeNi-cage(corns(OR LINER lif ap *able)
t 1110M TO DtsNr7rlt Tr1It'lOrN. 'SlelT lit\t
SAEDACCO n. n. is.
('ampul,N.,nw 16.INNER CASING OR 11 414muberpalri.bed-tunp! _. _ .
TROM TO a R Tritl A.r]. _ M\iTR111.
2.W'ell Conurvetitn Permit 0: 0 ft. 10 ft. 2 . SCH-40 PVC
Fur ail al,rtbi able arif prtm,t,ft r.Counrr Stale.t'ariarn-e.!gallon rag'.i r -
f(. n. its.
3.Well t'se fehcr•1:well user I7,SCRIMS
Water Supply Well: MOM TO DIAMITP.I C sQAT sItT THICIO4Fss MsrrNlal.
❑Agnculttual OMumctpal'Ptlblic ; 10 n. 20 R 2 •ia• .010 SCH-40 ... PVC
❑ othetmal iHeaning,Cooling Supply) ❑Residential Water Supply(Single) 1, n. rt. ia,
G
Cllndustriat'Comnkrcial OResidentral Water Supph lshnedl 1L GROV1
,ROM TO MATERIAL EMPLACT:ME IT METHOD A.\NOWT
❑hripption 0 ft. 5 ft. Portland pour
Noe-Water Supply Well: ft, n.
ICMoMtonne ❑Recosen ,
Injection Well: n. n.
❑,Aquifer Recharge ❑GroundwaterRemcdi:tion 19.SANDNaAVIL PACK pfa,,ReaMe)
i'N/)N I TO NsTrRt 11. YNH.N fMr\T NrTIH)n
❑Aquifer Storage and Rccos'cn- ❑Salinity Barrier 8 ft. 20 ft. Sand #2
0 Aquifer Test ❑Stommatcr Drainage n, i n.
❑Ftq)cnmcntal T/xhnolo4n ❑Srlbsidelkc Comm! so,ORII.LING LOG lanacb additional sheets if iceman)
❑Geot ennal iC'luscd Loupt ❑Tracer , Timm To DESCRIPTION It.l.r.harden"adwuet fret.drib as.cit.I
❑GeothcnnaliHeatingC'oolweReturn) ❑Odter(ctpiatn under 021Remarks) ft. ft.
R. ft.
4.Date Well(%)Completed: 7-10-24 Well IDoM11-7 ft. -
rt.5a.Well Location: R. ft. ‘-a'L.,.! vti.D
Pharr McAdenville Corporaton R. IL + AUG d 5 �024
Facility-'Oc set Name Facilns IDr.ifappltcabkl -
R. h
ifrC3'rtr._Flr...
100 Main St., McAdenville, NC, 28101 II. ft. eftFr ti_ $4 11'^;;I LWI
Plnsical Address Cats.and Zip 21.mums
Gaston Bentonite seal from 5-8'
r,.,a,.n P.necl lac w,fu':n ion N❑ 1 PIN I
its.latitude and Longitude in degrees,minutrshecnnds or decimal degrees: 22.Cerdficatias:
if cowl(li<•Id.laic Iai t,.io Is.rdlicknll
)\ W yf�� - 7/17/2024
Signature
' or:.'rL 1',: It:o.`Sa:6 5-- - i �+c�✓t
lime
6.blare)the wants): 20 Permanent or - 'Temporary. $1 mgnuig dr JbiRyrafr 5,.�':css .twv
w++Ir.rte)comb rurterl Art accordance
corn*1 Set NCAC 02C.'lr� Y,:M.7A.::2 .0200 Well Canatns-rirn Sraahtrds ord rho:a
7.Is this a repair to an exiatiog well: -1'es or E No t'rpr n(rhir re:ord hat been provided to the 00N owner.
111613 41 a trprtlr,fill.err knawo 144l1.onanw tarn nt)or •eroon an.l,,glom die,iornrr of Mr
,Asir under I2I m oar-1:x motion or on the bock of this form. 23.Site diagram or additional well details:
You may use the bowl of this pate to pros irue additional well site details or well
8.Number of wells co astrmied: 1 constmction details. You mils also attach additional pages if necessary.
For mainple MI:eel/nl IN n.rt-wwrrr rupph weal ONLY aura the Rime tnn.trnerkM ...0 t,.n
sdmiranr form. SUBMITTAL INSTUCTIONS
9.Total well depth below laud surface 20 (no 24a. Fur All Wells: Submit this foam within 10 dass of completion of well
For mairipk wells list all drlahr ifdeirrnr(example-*Nor) .,:41 2'JoYI construction to the folklmng
10.Static water level below top of easier; (ft) Division of Water Resources,Information Processing I.nit,
!(wale,(, .71r a/.orr.asnng..tr"+ 1617 Mail Srrsire('cater,Raleigh.NC 27699-1617
II.Borehole diameter:8.25" (is) 21h.For Ilthsrtien Well%ONLY: In addition to sending the form to the address in
24a abuse. also submit a copy of this form within 10 dins of completion of well
t2.Well rnostrwetion method:SSA cot min knon to the following.
u c.a lect.roan,cable.direct push etc.1
Dhisiun of Water Resources.Underground Injection Control Program,
FOR WATER SUPPL1 WELLS ONLY: 1636 Mail Service Center.R:Ilrigh.NC 27699-1636
I3a Yield ICpmi Method of test: 24e.For Water Supph K Injection Wefts:
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Also submit one cops i l this form milieu to doss of completion of
13b Disinfetinn type. Amount: well construction to the county health dcpenntrm of the counts where
constructed
Fonts(1W-t Non!'Carolina D.sparnrcm of En.nolule7u and Natural Resources-DisKroa of IN.&r Resrnrts Ho sot kugurit 20 I?