__20220311 (39)

WELL CONSTRUCTION RECORD O
For Internal Use ONLY:This form can he used for sinrk or multiple wells1.Well Contractor Information:
\
1l.WATER ZONES .,;',
John Eisenman FROM TO DFMCRIPIION
Well Cor tactot Name ft. ft.
ft. ft.
4439A
NC Well Contractor Certification Nant er 15.OUTER CASING(for muli1 asedrelk)OR LINER(it'applkabk)
FROM TO DIAMETER r THICKNESS MATERIAL.
SAEDACCO Inc 0 it. 50 ft. 6" is. SCB-40 PVC
Company Nome 16 YNNER CASING OR TUBING( iotherma)cIbsed-loop
FROM_ TO DIAMETER_ THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 72 ft. �2^ ►n- SCB-40 PVC
List all a}rplirable well pri nits(Lc.County.State.Variance.Ireectial rte.) ft. ft. m•
3.Well Use(check well use): it SCREEN - -; '
Water Supply Well: FROM TO DIAMETER MOT SIZE THICKNESS I MATERIAL:
0Agricultural OMunicipalfPubtic 72 R. 77 tI. 2^ in. olo SCH-40 PVC
OGeothem)al(Heating/Cooling Supply) °Residential Water Supply(single) U. h. in.
°industrial/Contmercial °Residential Water Supply(shared) ]A ��FROM TO MATERtA1. I EMPLACEMENT METHOD A.AMOUNT
❑irrigation 0 Il. 50 it. Portland ITREMMIE
Non-Water Supply Well: 0 ft. 68 ft. Portland TREMMIE
6DMnnitoring ORceoel)•
injection Well: ft. ft.
O Aquifer Recharge °GroundnaterRcntediation '19.SAND/GRAVEL PACK'Iif:ygdkabl4)
°Aquil'erStortge and Rccosery °Salinity Barrier FROM Tr ( MATERIAL (NVI.A/FYtE\T'.NMTNnl1
70 11. 77 ft. FILTER SAND #2
°Aquifer Test OStorm ater Drainage ft. ft.
°Experimental Technology ❑Snhsidence Control
20.•DRILLING LOG(attach additional sheets if ncccaars)
❑Geothettltal(Closed Loop) °Tracer FROM TO DESCRIPTION fcohr,h.rdnem,wat'nrck t.pc.0.ti,i On.t4c.1
°Geothermal(Heating/Cooling Rctutt) °Other(explain under 921 Remarks) 0 ft. 35 ft. Brown Silty Clay
35 ft. 50 ft. PPIR
4.Date Wcll(s)Completed: 1/28/22 Well iD#Dw-2MAR 1 4 2021
50 rt. 77 ft- Bedrock
Sit.Well Location: ft. ft.
Tank & Tummy #9 ft. ft.
Faciliiy/Ch%n:r Name Facility TDp(if appli able) f1. It.
1025 NC Hwy 62 E. Climax, NC 27233 Guilford County, ft ft.
Climax, NC, 27233 Plnsical Address.City.and Zip 21.Rii,ARK&'-' '
Guilford Two foot bentonite seal from 68-70'
County Parcel identification No.(PiN)
Sb.Latitude and Longitude in degrees/minutc/secondc or decimal degrees: 22.Certification:
(if nen field,one lattlorts is srifticicid)
N
Si^murr,off:r i / L- Date
6.is(are)the well(s): RIPennanent or oTemporatl' M +rgnn.krs,�rh + t r,4_,,,,
��d.•,,, r »7 j,nrSi nvCfrif In nr'nrrlsrnrr
with 154 NC4C 02C.';<-:='-,^'t ,C,i..r 1 .0200 Well ll Crnrsrroerk'n 5raa4,t,els stair their a
7.Is this a repair to an existing well: DYes or 'IDNo ropy of this reronl htta brrn pnyitleil to the civil owner.
If this is a,epale,fill rat tarsus,teen ennsnurtlnn Information ation lad opted,'rile suture rif the
repair under 02i remarks senior,or em the bark of slily firm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 Contraction details. You may also attach additional pages if necessary.
For multiple infection of near-sinew snppss n•eis ONLY with the same consfruclion,ton errn
so}rmit one form. SUBMITTAL INSl'i1_CTIONS
9.Total well depth below land surface: 77 (ft.) 24a. For All Wells: Submit this{fonn within 30 days of completion of well
For multiple isrllt list all depths If different teyr mpie•36S'200"anif 24'um construction to the following-
10.Static water level below top of casing: 75 (lt.) Division of Water Resources,Information Processing Unit.
If wafer level is above easing,use " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:12.25"/6" (in.) 24b.For iniectlon Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this foam within 30 days of completion of well
12.Well construction method: BSA/Air construction to the following:
(i e.auger.wary.cable.diced push etc.)
Division of Water Resources.Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.For Water Supply&Injection oils:
13a,Yield(gpm) Method of test:
Also submit one copy of this fora) within 30 days of completion of
13b.Disinfection type: Amount: ., well construction to the county health department of the county where
constructed.
Form CiW-1 Nonh Carolina Dcpannent of Environment and Natural Resources-Division of Water Rt ousts Revised August 2013