GW1-2022-02959_Well Construction - GW1_20220301

WELL CONSTRUCTION RECORD "`
�\ For IRenml Use ONLY:
i;b fonn can M used for.sinrk or multiple teclls
1.Well Contractor Information: \
I&WATER ZONIfS t
John Eisenman FROM TO 0F3CRIYt1ON
W01 Civarrcwt NanK (I.
4439A
NC KrellCoraractor Certification Number 45:OUTFRCASiNG.(for muhicai8dweRs ORLiNER'if.a Ikable
FROM TO nMAIFTER- THICKNESS MATERIAL
SAEDACCO Inc 0 ft. 48 (1. 61' ta. SCE-40 PVC
(:ongr;uq'N9nte 16.YNNBR CASIN OR TUSIM crttecrmid iosed•loi
FROM _ TO I)MMETER TIIICKNESS MA7T._RIAL
2.well Constivetion Permit N: 0 ft. 65 A. 2" irl SCH-40 PVC
Irrr rill rrpyilicnblc µelf Irrtrnitr li:c.C.mmty:.Srerh�.K�rirrrrre.Iryat)a1 nr:) fl. fl. tn.
3.'%Ydl Use(check well use): 17"SCRCiiN
Water Supply Well: FROM TO i11A+IM-14 ti1.0TM? I TIHCKNIM I MATERIAL
i'Itlgricultural bmunicipaliNbiic 65 A. 75 fl. 2" in• .010 SCH-40 PVC
oGeothcnnal j"Healing/Cooling Supply) OResidential water Supply(single) ft. it.
0IndustrialtConmiercial i ikesidential Wier Supph,(shared) 1 FROM
TO MATERIAL I F.MPIACr MGYTMFT710D C,AMOIi\T
❑1ni ntion 0 ft. 48 (t. Portland Tremmie
Non-Water Supply well:
0 ft. 58 H. Portland Tremmie
®Monitoring ❑Itccovcl)•
injection well: A. n.
❑AquifcrRcchirgc AGrpundmwcrRerucdimion 19.SANDH:IUVELPACK d ilteable
FRO dl 7Yr MvrV.RLAI. EMYIAI`r;�ri:NTMr;TH01r
❑AtjuiferSiorugc and t1c6vct), ❑Salinity Harrier 63 ft. 75 ft. SAND' #2
❑Aqui(erTcst O.Storma;ItcrDrunanc
❑F>rcrimcntal Technoloa ❑Suhsidcricc Control
20.'•DRH.LIigG Nita ad diiioaill Avetsif necr run'`
❑Geothennal(Closed Loop) ❑Tracer FROM I TO 11MRIPTION krobr.bardnel.,01-rock Opt.013n tbe.de.)
❑Geotheonat(HeauneiCooline Return) ❑Other(ex lain under 021 Remarks) 0 ft. 48 ft. silt sand clay
48 ft. 75 ft. ROCK
4.Date wc11(s)Completed: 2-9-22 Well n#Dw-z ft. FL
5a.Well IAlealhln: ft. ft.
Exxon Gas Station ft. ft.
Facifil))0%Vm.r,lan>c Facilih'fog 0rapplimblc) ft. fl.
I'i ti
913 W. Main St., Yadkinville, NC, 27055
Plgsital.Addrrss.City.and Zip
21:RCMARK.4
Yadkin Bentonite seal 58-63 ft
f:atuth' l'at'sCl Idenlil`tcattnro'No.(Pi\)
Sh.Latitude and IAingitude in dcgmc%1minutcslsccnndc or decimal degrees: 22.Certification:
61".1e11 field,eir 1.100ty i>Sic(tin icul)
'
2/16/2022
Slt[Ulllr'Of F1•�:`.1 `I'L hP Date
6.16,(are)thewell(s): MPermanent or OTemporaty l/ uI. �s ~'r.Wrc�ra
M sfgnbq rbts fire... A. r..,rs�..a:.t.i unurted err aetorrhmce
with r:SA/)r('AC{IaTC �,' Well C 04stRertion Stai-defids and Av a
7.Is this a repair ft)an existing well: OVc% or Rf No ropy nJ this r,•crmf ruts lwrn pnmld,•r1 to Ar evil rnrner,
If this is a rep air,fill rxrr kronor well rotrstntrllon brforowdim depth eyttgin die mtrure of the
reluvir tumferd21 rrmark�s.rjinn ar on thr bra'A of thh juror. 23.Site diagram or additional well details: .
you nlay use the back of this page to pro%ide additional Weil site derails or Acell
8.Nutnbcr of wells constructed: 1 construction details: You'Hlly algo attach additional r0ges if Jim-essaty.
For omidple lirfecihm c#ova-umer snT1>f+"heirs ONLY ufrh roe some eons►ruedon.you cmt
sahmit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth ttdon land surface. 75 (ft.) 24a. For All Wells: Subnut this form within 30 dams of completion of urll
F'nr owNple wells Misr op depths lfdfferemr(e%rut pte•,?e,200'wwl 2P.1 ) construction to the folln%ing:
10.Static water level below top of easing: (ft.) Division of Water Resources,information Processing Unit,
If umer level Is above reusing;tese 1617 Mail Sm'ice('enter.Raleigh.NC 27699-1617
11.Borehole diameter..12 u/6" (in.) 24b.For Initriton Wells ONLY: h►addition to sending the form to the address in
24a above. also submit a copy of this form within 30 days of completion of well
12.well construction method: HSA/Air Construction to the follo)ciogi
(i.e.augm rolan•.cable,direst push etc.)
Division of water Resources;Underground Injection Control Program,
FOR WATER Sb•PPLX WELLS INLV: 1636 Mail Service Center.Raleigh.SC 27699-1636
13a.Vidd(gpm) Method of test: 24c.For water Supply&injection Wells:
Also submit.one copy of this form within 30 days of completion of
13b.UizinfiYxii)n»pe . Amount: %veil construction to the country health depanmeru of the county.wherc
constructed.
FoonC,1\r-I' !ForthCamlimU-prinxinoffm rojun ruandManualResourees-DivisionofK'aicrResources Revised AuguSl 7-013