GW1-2022-01320_Well Construction - GW1_20220124

WELL CONSTRUCT 1ON RECORD forirandi UseON.LY:
Ms Form cam be nazi W single or multiple wc8s
1.WeR Contractor Information:
John Eisenman PRO" n1+YSL'itlp!ttOX
t���i.It t"tt!'RRrttC8CR1 Nam
4439A
NC well C'otrtatctor Cenifmstii3n Ntirrlter f5�O1 t:M,C 4 1Eitr "nT�` is'Ra* '`'tleteble
FROM I To PLAIMr.TER THICKINW5 stATEMAI.
SAEDACCO Inc 0 fL 20 fL 211 SCE-40 PVC
cAl"scull.Kass [6."I E •C 1 G+OR Lt IN+ : rimzt`t7+re �uti v. ;
t7R01I TO DL4Att?TERI THIC MSS MATFRAL
2.Well 05nustrugtinn Permit IN.. (r fa
1.iasAJlr.�g,iit-ablr.ureJP pemaiaa ie.;r.C'ouaars.5rs'ar,t'tlrJttrMV',Ir�[iPt7�er,�.l �+
ia.
3.Nvd1 Use(check well slim).'
Water Well: MO M TO - . . 01-049TElt_.,v RMS M T11"n
iI nituml ills micipab'llablie 20 ft. 35 (L 2^ in 010 SCH-40 PVC
043jeothettlnil(HeatingCool tg- Supply) OResidtntiai Water Supply(single) fL ft, Rx,
77
0Ittdua0allcctnimen:ial C Residetfltsal Water tpts-(slwmd) �oht Tn . nt��trairt. � � �tTat>~n OD&AMOUNr`
❑lnip n 0 fL 1 15 fL Portland Pour
Noe-MraterSuppli well: rt. rL
Mmonitm ln" ❑Rot nrrt} - — it
-
Ig]'c on Well: rt. ft.
ClAquircr-RccharF l CrratlRdtstilt r Rettuxliation W, ANt} TA_ `fllf tl" ttte 4 .
ittAY, t,
MAgttefer SloMe and lt,teovers' Qsadinity,flareicr 35 0. 18 M SAND #2
t7AyttifcrTest QStOMMturrDmio;lga
l7Prg rdmmil Technology QSstbsid=e Control
>Ylt�lt11,1311taf "� 'cH`xdditi ' iihesirfti" s�rr,•'s.,_ x.
OGeothetrtatl(Closed Loop) [Tracer YROM 170 D�stTittrtt� toisr.fiirdnc��xn+rci:_ �,��_
0Gootitc Mi tRLA Ctvoli Return) OOtimt( iu ulider#211 Rema&Lj 0 iL 35 tr, silt(sand clay
iL fL
4.11ate W0ll(s)Completed: 12-23-21 WeUID#MN-3
tt. fL
a.� t 11 I a,�atttt6: rL ft -2 4 2C�'
Antioch Food Mart ft. (14
FwilfttMwmrNam F GMV tDl:(if app1ic3b1e3 T.. --fL _ �,,., n.•�..,. �.. «.«a .�����
2940 US-64, Morganton, NC, 28655
F9ttsical.Aditss.City.and Zip
Burke Bentonite seal from 15I-181
010144,' Prrts9lj3aiiitlfllipiiNo (PINI
ilk l:Rtlhttl> and langitude in degreeNmilttlwWwwads or decimal degr ew. 23.Ccetil'eeatiten:
titttelt fdpltl;l'�Ltl7nue ls;:td(ICiesdy
IV 12/27/2021
w' __.. __. ...r
sigmidrC
6.Is(;IIY)the well(s): WN-1manent or aTemporar}' 114 xlgab, alr�r fur„iL cif iru.MS ,y'?e. `:r 7i4 r s!,,manwied an=,WMirr w
with 15A Ar Aef)„. '< =Y l Eris ;:'t,Oslo)Weil t znfinerfm Sa2aarkwds midt{t� a
7,is this R rel air to an existing well: :Ales or K'No !U4 hrEa JNQOI'"�4 rn MW\tr)l d 01M
41 this at a re�i r fill pme*,ri()Nn well ec wnr17f4n iiaformnit,n taid e splaht the o-laWre of die
repair undiT r2f retmarkv sft-ivr or xm Lye hca;h rtf 1A&farm 23.Site dtWom or additiutlal well detalls:
You may use The bactz of this 11692 to protlide additional it°dl site d%dis or well
8.Number of welly coustrurted• i constmcdon detitils. You olay also allach*Mliottal pages if It MS .
For Arafoj*i*al m Err"MI-WAtar a rp6-MIS ONLY w1rh dir same emrsftedow.yolt Egan
submir emue form. ��il MTTAL I N,SUDC PIM
9.Total well depth bekw land surface: 35 (ft,l 244L For AEt Wellsr Submit this form i%ilbin 10 darts of cotttrttgion of well
For m,"hi dr.wear fimvff ifr prbi 11 dJ*reau(exampfe-,t90W'and 2@ ftgyr Cnn%uucftn to the fotlPM og-.
10.Static water level beloul top of rashly;, a) Division of Water R'esaurco6 lafurmstion Vroetwoittg 1101L
),mower lruiel lxsrhove rrasin.;,sate" " 1617 Mail gee iec Center,ltaleig}t, YC 276911-1617
11.Bgrrhnk I)iametcr:S.2511 ;n,} 24b.Fat•jgjapa W ells ONLY: In addition to sending live faint to flee address ill
24aabove. also submit a coo-'of this farm t1itltin 10 dms of completion of treil
12,Well vortstritcflon method. HSA LVIlstniction to the follmVia ge
(Le.mWr.nmare.cable.direct,push.et-..) RH•Ision of Water Resources.underground InjMton Control Program,
FOR WATER SUPPLY WELLS ONLY; 1636 Mail Service Center.Raleigli,VC 2 649-1636
13;1 11eld Wm) method of test; tic:Fur Water Sue&&lip ectioa wells:
Also submit one copy of this fortes within.30 days of cotpletion of
131r.111sinliyxlnn tt Amount: tvctl construction to the coupe} heAh dcpadumnt of the Cmmly axbcrc constructed.
Fenn G lr-t .'4"h Carahm t k mmm or£mammuw and Nattteal ttecnawag-Ditir as of tiljter ReuUMILet iced Ate�P t i