GW1-2022-04896_Well Construction - GW1_20220525

WELL CONS'i'RUC-i'ION.RECORD For lrrmalUwONLY:
This forin can tc ijwd for si mla or nndlipk%'ells i
1.Well Contractor Inforniation
14.WATER ZONES
John Eisenman FROM To DF.ti(.'RtlllO\
WcIl Caitrictcr Kano
rot. rot.
4439A
NC\Vdl ContrattarCcni[icationNulrticr 15.OUTER CASING(ror Inullkased"ells►OR LINER(if ap ikahk)
FROM I TO D1%%ICTiiR TIIICK"WsS- - NIA MAT.
SAEDACCO Inc ft. I (I. i :ia.
M.INNER CASING OR 711BING t$tolherroA)chiwd-lm O
-FROM -TO 'M IFFUR: -I THICKNESS 'MATERIAL _
2.%Veil Constivet ion.P&mit#: 0 ft. 29 go. 2 SCB 40 PVC
Lirrull r.;�,lira(ih•r:rlf p.'beeitr(i-r.Cnu»fi•,SJu:r,lSriarce.•,�f}r�Uq�h-.) --'�
3 Wcll,Use(check well use): tv.s(REEN
\\'atcrSupph.\Yell.; FROM' 1 TO- DIA31r.7 Rr SLOi517): i Tlil(is\FJS 1 MAWRlat.
L7Aglicn!(iltaf LlAitinicipaGl'ItUlic 29 R. 39 `ft. 2 in.. ' .010 SCH'40 ( PVC
0Gcoiflern,01 Meat inglt'ooling Sul)pipp ©Residential Water Supply(single) rl tl: in.
Dindumialfconunercial 011 sidmitiab Wa(cr Supph'(slumd) 1 TR.GROUT
FRO}i 70 :?IATERWI: I EAfTL.10E51LtiT\IL'r110D&.1AIOIINT
❑IrriiLrtion 25 ff. 0 fL Portland ,Tremmie
No nr,%Vater Su pply Wclh, - !
rot. ff. I
�jVfol>itaring ORccoitry
InjecNunAVcll: f.. IL
QAgllirdr Rcchar.g ❑GrollndD;ilcr RCincdi ition 19.SANDIGRAVEL PACK lif applicable)
FROM 70 EMPt.A(XMM T HITII0D
❑Ai)nifccSforrSc'irrdR covcry ❑SalinityBarricr. 39 rot. 27 rot. SAND l#2
❑AcipifcrTest 175toimiatcrDiiinaggc rot. rot.
❑Ex cniTcntrd'fcchnolnny. ❑Sohsidcnc-c61idrol
Ni.DRILLING LOG(lutich addilionul rheas if eceCWfli9
OGcotheinial(bused Loop) bTraccr I FROM I TO (tlr.bardneet,sa1m-k1, mRvay.Cie)
❑GM.knilal(Neathm/Coolive Rewtn) ❑Other(explain untler:P121 Reuiati;s) 0 It. 39 it, soil
n. rot:
4:Date Wetl(s)Completed: 2-16-22 Well 1Ddn1W-33A
fl. ff.
52.'\\ellLocation:
ff. ft.
F¢cilit},Chsi+rNumc Facility 1D�(ifdpplablc) ft. ft.
AV
3900 Electronics Drive Raleigh, NC Wake County 35., ft. p
Plnikal Aildrtss Cin'•and Zip 21.KL(ARKS
Bentonite seal from 27-25ft
Caciuh I'airel td_nli6wi oi:No,(PIN)
5h.Latitodc anal l:onotude in dcgrccslminutt:alscconds,or decimal dcgrecs: 22.Certification:
OJAI ell field.prk ilt-401:8 ia'gidGckrd)
f'
-
N \Y =-yam- _2/18/2022
5I�tutur
6.Is(are)tllc wcll(s)f XPermatient or ❑ emporuy. far artnti thuroan,:fir PE%°!,( y 5 „�� I r+7�JracJcd ire rtm'ronranc`c
r iA 154,YGtG OIC=t�'��-C•e:(.i C Aak�Il e'i!ConcfRrr;kur$rar�fcuils caul t/air u
7.h this-a repair to an"tAsting)tell•- o Ves or- KNu cep»n;'rhis a•ronllrsai•.»pnndr ai rn the:irl1 rnr,i.•r.
!f phis i{ra reivir.roll4-n,rlamai rerll rairnxaipq iirfonru:n.'v,l Turd eXploi,l rho°»nest.•r f(he
reK..ir ardrr 021 reMarla arriiun or nut the bark cif thus form. 23.Site diagram or,additional well details: „
You liras•use ilie back°of this bulge Io provide additional well site details.or well,
8.Number of hells coiL41711cted: 1 cvirsMclion d to L' You,,mv aLso'attacli dditioirai pabes if uecemi. .
FOr mairlplr briecrion Of arni-rrmrer snpp{e ieelra ONLY i0th rile some.cooIrrifedrol,}on curt
s h»riei»efnrr,. SUBMITTaLIhCTUCTIONS
9.Total well depth bclal�land surface: 39 ({t,) .2{a.,FDr All Wells:. Sub»ri1 tlds,tome within 30 days of complcliori of-Well
For,nalriple rrells'lisf rr1144rrhs rj riilSviJu terra pie-:ti,=0D'evk!2(e lGhy) Construction to the fo_ilolnir1g:'
!O:Static niter levelbelolt tap oCcasiug (fL) Division of Walter Rc+iiurces;Informati.-n Processing Unit..
IG17.hlai[Slrtice Ccntcr;Ralcl fi,\C 2 76971617
1 n:uer r:rllsabcnerasiuq.»sc"+' � .
f 1 r
11.13drehotc diametcr.8 (in) 24b.For hliecffno Well,;ONLY:',fit addition to.sending tha fom{to tiu.addresc in
24a above. also submit a cop}' of this.four will in,30 days of completion of well
12.\bell construction method: HSA constmetiml to tllc_folloni iug:
(i.e.aug r.ra(ar}•,cable,dix�I posit,c(c,l
Division of Water Resources'i Undet•l round Injection Control Pii) rate,
FOR NVATER SUPPLY WELLS ONLY•- 16316 hiail Service Ccntcr.Raleigh,NC 27609-1636
1lcthod of test•
l3a ti add( ) 23c.For Water Supply&injection Wells:
g(rm
Also submit o{ `copy Of this fo1111,1t1thill.?0 days OfC0111pleliolIo
13h:I)i�infeaKion qpe Anmunt•. sedi-construction to the county Health depanmarl ol`tlic.cwmn n111erC
consinicud.
Farm GW I" Nonh Carolina U:p:utneni of Enciromwitt and Natural Rewurces-Division of WnicuRe-oirom Revised August s01.1
i.