GW1-2022-04875_Well Construction - GW1_20220525

WELL CONSTRUCTION RECORD Far Iticlual Usc ONLY-
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L,weit Contractor information: :7777777-777;�_
ALAVAIER ZONLW
John Eisemaan
1V01 Contractor Kamg
to tt.
4439A OR_UNEX-lif atlitt
A&MURCA,
FROM DtAITUER TMCrCNTS%nIATEDFAL I
SAEDACCO Inc 0 it. I IS (L 12"
UNG Wis", clo.td­lw
,�66.01 1N IN ER ICAS I NG,0 H
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Calr4caw Name 1 70 ('11MMUMUC ICKNESS IIATFFUAL
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2.Well construction Permit Ph ft ft.
Lim AX amlira"Ife vwlfverwils Ux. Variame,11)"SC664 cu'-) _n. -ft.
3.Well Use(cherk well ow): 4 St: FEN
FH0%l L1 1 DIAMETER storstyx NIATIMIA1,
Water Suppkv Well: is ft. 38 It. 211 C
Ukakultural LiMuoicipaltPublic I
DGWElwalial Mcafio'qlroolirig supply) DResidetitial Wilcf SuPPb'(SitIL110
AWGROUT_�
riludugriat1comolcrini OResidenrial WatcrSupply 0=4) il FROM 110
NVATUMA Ew M* K%*r_N1ETllOD.Q ANIOUNT
0hTivation 0 ft. 12 ft. Portland Pour
Non-Water Supply Well- rt. ft.
®Monitoring 131tccowry FL
Iujecl(all%Veil:
DAquiter Redwrgz 00roundwilcr Rcmcdiiiion el-
A FROM TO I
0AqaifevStornSeir4R=vy osilinity Rimer 16 A. 38 ft. SAPID #2
D Aflufficir Test Mtormwalcr Drainage ft.
ElExpzrimcmal TcchnolMr Mubsidcwc Cordral '70.DRFI, 'G LOG 4ailich addillimalilkels,if h'-C"%ai*l
c3l3kodwsmal(Clused Lvap) DTra= FROM To DEWRIFF10%
DGeockrutal(HeatimpCooling Rctunq E30ftrtexplainunduT#21 Renorksl 0 it. 38 iu clay/ sand
ft. a (L
4.Date Well(s)Completed: 4-26-22 Well IID#SW-1() Jr. ft. Q v
Sa.Well Ulcrtian: ff. It. PAY 2 5
Broughton Hospital A. (L
Faafily,10,AocrNxTe Facitily 11),10fappli-mble) 1 T_T 1-;T'41-MC�1 ON'
ft. IL
l000 S. Sterling St., Morganton, KC, 28655
-77777
Pimical.,Wdrno,City.and Zip 21 itf 1nfARK47
Burke 12-161 bentonite seal
Comity P.,irrel U;n1if'=aftw No.WWI
2-1. tifica
5b.Latitude and I.Ongit"lle in or domunal degrcw. Cer tion:
(ifucti Mil,ow lav'ImLa 1%v.dl16=n
5/l/2022
W
Dale
6.ls(are)thevicll(s): MPermanent or liTemporary
kow v o_1(11)114'Iff Ct 0 S rrZ 16101 15f,WIh i e 4A 40 td OW 11
7.h tft6 a repair to an existing ivell: OVes or KNo
fflhh'is Pepid".filf(wl 0(ow7a inforwavot cued esplaill file Itou'ler of tier
repairowler Oil ranarki AwMao or an dhe,hawk fit lithfiorm 23.Site diagram or additional wd I details:
you tuay use th.,bad;of this page to piovittz addilioital well site details or%veft
S.Number of%velts catustructed; coustiuctiondelaiLs.
SUBMI L INMICIPON—S
9.Total welt depth below land surfaces 38 (ft.1 24a. For All Wells., Slibudl this fumy within 30 days of completion of%icll
Foroij,10pie tv"115 M'4 vildelahl ifdifivew 4evew 1ple-34-N39,411111 2CP 104)) Construction to qhc rbuoniqq:
it).Static water lLwel helow top(if ca%ing; Dh-6iun of Water Resources,Information Processing Unit.
ff-mwer 1--vrl is a!e-4" 1617 Mail Serviry Center.Raleigh.NC 2776994617
11.BorclwL-diameter-S.25" ONLV.- it}addition to sendike the form 10 EN-1 address in
"'a above,Aw submit a cop), of this 1`0101 Wilth't 30 da� Of WHIPIC4011 f veil
2_ S 0
It Well construction method:BSA Constroctiou to the follml ing;
ite,angur wuriL.cable.dixcl tusk etc I Division of RaterResources Underground Injection Control Pro;xr2m,
FOR W.AXER SLTPLV WELLS ONLY' 1636 NUtt Senice Center.Raleigh.XC V699.1636
l3a.Vidd(gpm) Method of teat 2U.ror Water Supply&Inicettv a%Vcltc
Also milutift anti:copy of HAS 16)'111 %villfill 30
jib.01-intectlim type: Amount: well con5trurtion to the calmly ho-afth&P.-HIMC111 Of[tic C0uUq'wlwn;
consinictcd. I
Fann(rw-t Rciou=s-Dvewoner\Vaicr Rmouram- lte%iscdAUgUA!4D