GW1-2022-04475_Well Construction - GW1_20220509

WELL CONSTRUcriON RECORD ortttcnnal Use ONLY:
This fonn can bo owd for single or multiple ttvlls /1
I.Well Contractor information: 1\1/CI
1tH`ATERZONCS
John Eisenman FROM TO DESCRIPTION
ftil Cintrictor Name
ft. f1. i
4439A
NC Well Comrdoor Cenification Number I&OUTER CASING for- Ill•eaecd w0s OR LI ER if a .Ikable
FROM I TO DIAMETER THICKNESS I NIATCRIAL
SAfiDACCO Inc 0 h. 18 ft. 2" in. SCH-40 PVC
C011111 lay F9nrC 16ANIVER:CASING OR TUBING f eoiberiaal ciosed4000'_
FROM TO DLAMETER I TaICKNess MATERIAL
2.Well Construction Pce7nit 4: tt. h. in.
Lirl tell applirahle'writ pen"&x(i.e.rounn'..Shdr.tariaare,Irgrsticn eie.) ft. f4 ln•
3.Well Issc(check tseil use): 17 5CREEN
Water Supply Well: F7iOM 1 70 PlAWM R I S1,0TS17T ITnl[1(\t\� \IATFRIAI:
OAgdcultural Cimunicipal,TUblic 18 ft. 38 ft- 2" inn .010 SCH-40 PVC
OGeothemtal(1leatioglCooling Supply) (Residential Water Supply(single) ft. ft. io
'18.GROU7 ;
131odustrial/Conimercial nResidential Water Supph•(shared) FROM TO MATERL4L I EMPIACEMF\T.NirmOD&AMOUNT
01rri •Rion 0 h. 12 h. Portland Pour
Non-Water Supply Well:
A. h.
mmonitorint; ORccovcry
injection Well:
QAquifcr Recharge OGrotlndwater Rentediation 19.SAND)GPLWEL PACK;(ir dkiible'
FROM TO _ M nYFRIAI. RMPI.AC.i:�tE\TMf'1•nOD
0 Aquifer Siornge and Recovery ❑Silinin•Hairicr 16 h. 38 h. SAND #2
OAgnifer Test OStornncater 1)rtinagc ft. If.
OLyfcrimcntal Technology O)uhsidcncc Control
20 ARMUNG LOG(Attach'addltioiiel sheets if licccssnn
OGwthennal(Closed Loop) OTracet FROM TO DESCRIPTION(tubr.hardnesiwdl'rockh • n.ttc./u:l
ElCimthenoal(ReatineiCooline Return) oOther tea lain under 421 Remarks) 0 ft. is ft. SANDY CLAY
15 ft. 38 ft. ROCK
4.Date Well(%)Completed: 4-20-22 WellID#MW-2R
n, h.
52.Welt L/itathin: ft. ft.
Tomberlin Grocery YL It.
r
Fac.0h/OwnerNamc Faciliil lDX(if aWli:ab110 fl. ft. •It
8722 Old Perry Rd., Monroe, NC, 28110 rt, ft. till
Plnsical AddrrsK Cite.;Ind Zip 2ri RYDIARKS'
iMII
Union bentonite seal 12-16ftT' i u. C r.+n
F`s,t: r. »v ��•
(:omtihy PaitCI Id iIirw_iiioiiNo.[PINT wr�t �tr.• ti;r:v•dr;n r
5b.I ititude and I ongitudc in dcgmcrr/minutca/secondc or decimal degrees: 22.Certification:
(itwell Pield,Rae Intlong it ciJliei tu)
��• _ 1/2022
Slrnstur of r 7 Datcp
6.Is(fare)theivell(s): -ZPernfanent or OTemporan•
J3t srgnur th+s fin r.. +(• ...... .. q:.
with 15A NCAC 02C Well Conorr,r:rion Sondards and rbat a
7.Is this a repair to an existing well: OVes or MNll t'rgmnj dtis rnran'1 hmc In rn pmrtrl.•d to 1'hr on l!anvt.r,
If-shis is n ti prlir fill intt Fnnlon well cotutn+riimrttrforotailon teed r.cplahi the nantre of rho
rtlnsir tattler A21 r:-markr,r 7iarr or Cur fhr hrx'L tifthicJ+,r»+. 23.Site diagram or additional is-ell details:
Y(xi ma)•use tile.back of this page;to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You inar also attach additional pab*es if necessarv.
For innhlple igj&4on or»rei•worer stfpla�p t+•ells 0+V7-i•➢r•lrh der same consrruerion.cot+Can tBM ITTA1 1 CT TIONC
.,uhm m ir mi,for . s,- C
9.Total well depth below land surface 38 (R) 24a. For All Wells: Subnui this form within 30 days of completion of well
Fo r mohiple welh tact a0 de/uhr fJdift'rrrw(example.:t@W mil 26?10) eonstmction to the foltmting:
10.Static water level below top of casing: (ft Divishm of Water Rcroumes,InforTmation Processing Unit,
if-turret level k ahove e(jstng,us,'^_" 1617(Nail Service Center,Raleigh,NC 27699-1617
i
I1.Borehole diameter. (a) 24b.Far blieetlon Wells ONLV: fen addition to sending the fond to lite addmss in
24a above. also subunit a copy of this form within 30 days of completion of well
12,Well construction method:Air Construction to the following':
(i.c.nogcr.roLir•,coble.direct puck cia)
Division of Water Resources,'Underground Injection Control PtnRuany
FOR WATER SUPPLY WELLS ONLV: 1636 Mail Service Center.Raleigh,NC 27699-1636
13a Yield(gpm) Method of test: 2k•For Water SuPpiy&Injection Wells:
Also submit one cop)' of this form within 3(1 daysofcompletionof
13b.DisinfiYti(7n type: __ Amount well construction to the county hehlth dcprinmeni of the county where
commnictcd. i
Fonn GW-1 North Carolina Ucpanaxm of Encitulunciu and`aural Resources-Dirision of WiterResotrces Revised August 1-013