GW1-2022-04899_Well Construction - GW1_20220525

WELL CONSTRUCi'(ON:-RECORD For imcmilUsaONi;Y-,
5his Yorm can ba used for sin;ie or muhip)c sails
1:R'dl Cuitntcltir.Information: `
14.W.+riR ZONFS
John Eisenman FROM. rO, 1 oF ('RtnRIN
%VC11 Cohti-agcr Naau
4439A
NC Well Contractor Ccnifieaiion Nnn-ber 15.OUTER CASING fror nub -Astd wells►OR LINER(ir a ticabk)
FROM TO nmmri it Tlnct VIII . MATERrAL.
SAEDACCO Inc 0 it. 100 ft-,1 6 tn. SCH 40 PVC
Con4tinj�Milne. 16.INNER CASING OR 11111 inrlkrmal ck wd-loop
FROM TO DL1MET�L"R f THICKNESS MATEMI.
2.Well Construction Permit#: 0 ft. 110 rl. 2 SCH 40 PVC
lilt all cpplirahl r dal penrils'O.r.C'affnht Slate.Variamrr.Ir)raAal rir..j
rt. fl, in,
3 �Yc11.13sc(check:a cII psc)c 17.SCREEN —
Water Supply Well: FRom, TO DIAMF.TFR SL()TSV3: THICKN1t5 I MATF.RI.11..
ClApti:ulturdl. ONI.tinicipal.-Public 110 ft. 120 ft. 2 i"• 010 SCH 40 PVC
®Geotllcnital(1leatinglCooling Supply) 011esidenti3l WaterSitpply(single) ft,•
©LidustiialflConitncrcial Mesidential Water Supply(shaird) FRO ROLT To — MATERULL t Esurl 1erMLNT stsntoo s A1uocNr
❑irii ation 102 'ft. 3 ft. AquaGuard ,Tremmi8
Non-Water Supply Well:
3 rt., 0 p. portland pour
t�hlii nrtor i ng, l7Rccm�ery'
Injection Well:
❑A.quifer Recharge 0Gipmidnatcr Rcmcdiation 19.SANDIGRAVEL PACK fif t H able) - ---
FR(11T... TO: lL1TF.Rli1. FIPt10EMENT METHOD.
❑Afluffer.Su ragc and Rccoirry ❑Salinity Harrier 120 ft. 107 ft. SAND #2
❑Agitifer_Tcct ❑Stormil,ucr i?mina
. ft. G.
❑F pcnmcnial Technoksgy ❑Subsidence Control
20,DRILLING LOG(allmh additional%Beets if necessary)
❑GLodternud(Closed loop) ❑Tracer FROM TO DFSCRII'TIHNi,+br,hprJnca�,rfA'nM1,h fnn:vc.cff l
❑Gcodknnal'(Hca6ng_'C-ootiu'z Return) ❑Other(explain under 021 Reuratks) 0 .-ft. 39 rl. soil
39 ft. 42 fi. pnr
4.Date Wells)Completed: 3-2-22 Weil 1j)#MW-32C
42 rti 120 It. rock
5a.WellLucatiou:
MAY
Facilit lOss'il rNamc Ficilhy M."(irapp limble) � n .,.
> - " ff. it. i{?UY i 6)Tm
3900 Electronics Drive Raleigh, NC Rake County 35., , , ry, P.
Pins"r.51 Cddresz Cit}•.and Zip 21 REMARKS
Bentonite seal from 107-102
Cknmis fared ILL11 ii'tciliun No.(PIN)
5b.i::atitude and Longitude in dci_;tres/minutcslscconds Or decimal degrecs: 22.Certification:
(irucll fiW.01k:1:114mro is ctcfliciad)
3/2/2022
Signsttttcof '. 7 .` � Date .,_
6.is(ar'e)-the wcll(s): 1OPermatient or ❑Tcnt)ioran'- Br signu lets Jur 7:;i ! rh.�r cti S .r sCc ,muqucird,rr accordance
withL4ANCACt7:C,'1+:=-1: A 1C.0:(Mwell Coitsirieeri'mskuv4rrdswiddmru
7:Mix"' wrcr ah:to an misting h•dl: t716 or M No r ep .oj ddi rrronl has twe'll pr..:rifled in M.-iml owner.
If ells'it a mi-mir;(ill txrt0o'ieil well 1"forrrfrrivn rn d r- Wit the aimire of r/if:
re,wirimdrr021 remarks waion or(xt ihr bwC)L nfifns faros 23.Site diagram or additional well details:
You tray use the back of thispagi:to provide additional well site details or well
S.Number of bells constructed• 1 cutisttnCtiou details, You nlay also atiaeh tidditioltal pa -s if incessa'ly.
For piahipk iaferrinn of, fails ONLY)rift due mmccvnitruifinn.,vvu repo
aulndrm{cjomf: S IBAIITTA ;INST (-.TiONc
9.Total tell delitl lit elow-land m irface. 120 fn,) 2aiL [nr All W'dls: =Subntil ilus form within 30 tliays of compledoy of dell
ForInI,hipkwellt list cl rltpihS if fliJji'IIPIJ{rxarnplr-,7�':0j'oral d rnlllli} eonstmcti0n to llic following':.
10.Static�ratcr Ic+d bcloli'tali of easing: Di1•ision of Water Rcs;mrces,Information Pfucessiny Unit.
if water level!s rhot'r rasitr;i ax "+" 1617 Alan Smice Centcr;Ralcigh,NC 27G994617-
1 1.Borehole diameter l2/6 (in,) tab.Fnr ili icetlon-Wg11c ONLY.',-in addition to sending di`fonn to the addres in
24aabove. also.sitbotit a.copy of,.this fonn within- (!days of Conipletioti of well
12,Well construction method: BSA/Air construction to(lit following:
(Le.auger.rotary.cabtc.direct pNal>_ctc.)'
Division of Water R(sources Underground injection Control Pnlgratp,
FOR WATER SUPPLY WELLS ONLY.• 4636 Abil Service Center,Raleigh,NC 276"-1636
13a.1 field(g Method of test• 21c.For Water-Supply.l''inlrcthn n l�ell:
Also submit on copy of this foim within W daysofeompletionof
well constlnction'to aic.count}*health department of tlic count•wlicrc
i3b:Disinfection types,_ Amuunl:
constructed.
FamtGW-1 rnnhCarolinaDcpaiinentofEn irownciaandS':nurJResources--Divi;ionofWater'Resoras Rcs'i", _[igust:w13