GW1-2022-05473_Well Construction - GW1_20220601

WELL CONSTRUCTION RECORD Fur ltAcnutlUsoONLY: 39--73
This(ern 1 can be used for siuglc Or rnaltipk walls
c 1.Wet Contractor Inforutation:
7,14-1 ATER:LONES" -
John Eisenman FROM TO 11"S RIPT1Oti '
U101 Cormtoor Noma
4439A ft. ft,
NC Wcll Conl>acmrCcnification Nun bcr
t3,".OUTER CASING:foe niiGf=i="--ii'd7sYOR[1@fER'[tf"a"'fle96k "
FROM TO FL1rtitF.T6R TftIC[{VESS HATEftrAL
SAEDACCO Inc 0 ft, 10 fL 2" iu. SCB-40 PVC
VauVwq N;3mc 1.76:INNER`CASiNG'01t'.TLr611YG "ihtSe rifalcNrscdaoii
FROM I TO I DIAMETER 111110 NESs MATERIAL
3.Well Construction Permit R. ft, uL
1-frr all rl:,lirrrbl-vr.11 peneirr(r_,�.Cnrorh•,.StaJn,anriaucr.lry'a-dut r�r.b R, f4 i,r.
3.Well Use(Chock well Itsc): t7:5GR1ENC:
Water Supply Well: FROM TO I DIAbErtTER I SLOT SIZE I 711100ESS I MATERIAL
ClAgticultural ONfunicipatTublic 10 ft. 25 ft. 1 21' in, .010 SCH-40 I PVC
OGeothemtal(Heatiog,'Cooling Supply) ©Residential Water Suppty(single) ft.
DindusiriaUConimucial DResidea(ialWater Supply'(shired)
FROM TO NIATERLIL ENIPLACEMENT MET 101)S AhfOUNT
❑1ni •)lion 0 tL 5 ft. Portland Pour
Non-Water Supply Well: ft. fL
njeclion W l]Recovcq'
Injet;d4n Well: fL ft.
QAquifcrRccharge 130onndwascrRcuicdituion A9';SAND1C1(AVEt-PACii'pr YeleeybCcl-
FROM TO MATRIUA1, Ra�rl.�t(:F;\)ENT Mt:Tnit)n
(7Aquffer Storage atxil Recovery ❑Salinity Barrier g R. 25 R. . BAND #2
❑AquifcrTest ❑StormiivtcrDrtinagc ft. fL
❑Expetimcnlnl Tpchnetogti- ❑,Subsidencc Contra(
`•2oli/RILUSGaOG:fatlach addllioriaL"sheds if ncci�sstiir'v} • - "
❑G�otltenunal(Closed Loup) ❑Trlcer FROM TO n�seRlPno�trobrt,,trane�,s+,+4nkkf" nuck.i
❑Geodiemtal tflealigg Cuoliue Return) ❑Qllter(explaitt under#21 Remarks) 0 ft. 25 R+ sand clay
ft. ft,
4.Date Well(s)Ca►nple(ed; 4-28-22 Well tD#MW-13
fL fL
So,Well Location: iL ft.
Circle K 4660 'w+Cl — V t-LIF—
Facflily?'GivncrNamc Facility-IDr(ifappiicabic) - fl
n j *)n22
1513 E. llth St., Siler City, NC, 27344
Physical Addles_Cin.and Zip fl Oi m' an Pro r.^ t
Chatham Bentonite seal: 5-8' �i''�rvti7
C.'aunly Nrcel U-ndit•.a:dion No.(PIN)
5b.I.;Ititudc;Ind Longitude In dcgr•resfminurcilseconds at,decimal threes: 22.Certification-
(if%I ull 1W.d,olk!I:ullong is Srrlilek:ra)
N W 5/l/2022
Sigtulus :of ��:',+c::r,'3,L u+++ •':-- - .= C3a(c
6.is(are)the ivell(s): SlPennanent or ❑Temporat'p Q,abgnn+;bit �,,.. ,fr•,� fad•. `"�f was�.:NJ-.•!1++ny1rlrc'kv1 fir rK7•orrbr7re
Idol b.f.•t NCiC 0 C.'x+:��Y;; ;iCri. i'MC,0200 We'll Comtrr+rdort SkuadwAi wid Omsa
7.Is this a repair toanexiS$ng-well, EiVus or QPiiltt r<�Jr�diarre.+nil„rsfar..Jll,rnrirlidrnJh+,nllrnrnr•r.
1f ebbs is a rep'Ur,fill twit kuvnw aril roJu'rrucrl:,rJ irrforr•Jarlult wad explcrht the narejee of rite
rrhrir rarritr ?1 rrmerds.ttarrsn or cvt nc�hcu•.0 njrhls form. 23,Site diagram or additional well detait3:
You may use the bacl;of this pale to provide;additional well site details of icell
S.Nntnher of wells constructed: l eonstmction datuits. You pray aLao.diactt ulditiotwt i)a�xs if ixY essary.
For lttairiple!r(k erhui ar wm-wwer supl,J,•wdfs OjVLY,t•irh the 54vair a,restrurtlwr.vnr+c ern
.mrjon(rOne fort.). SUBMITTAL INST T .TIONS
9.Total well depth Itelolr land surface: 25 (ft,) 24a, For All Welk. Suhndl this form %vithin 30 days of completion of hell
For+trawl€rle Irt-llf list aff r"r•nJhs ?@afki':uu12F.ltk!'I consiniction to the foltonipq:
10.Static water level below top of casing (f4,) Division of Water Resaurces,Information Prucessing Unit.
lf,rarer h•vel bs above rasing,,rut'•+'• 1617 Mail Serriectenter,Rrlc gh.NC'27699-16t7
It.Borehole diamcka7 6" (im) tab. For I)tW. W0119 ONLY: In addition to sending ilk:fnmi to the addfm in
243 aboi'e. also submit a copy of this faun within ?0 days of completion of utll
Ix.Well tnnstntcdou method:Air Rotary cansiniction to the followin_e:
(i.e.augen rolery,cable.direct pusla etc.I
Dlv6ion of Witter Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
134L Vield(gpm) %lediod of test: 24c.For Water Supply.CC 1plection Wclts:
Also submit one Copp of this form within 10 daysofconlpletionof
13h.Diainketiun hpe. _ Amount: %veil consimction to the count}'1wIaith depantncat or the ctnmty wbcre
constmewd.
Fa fin GW-1 Noah Carolina Wpanittem of EnvirBWnctu Sad Nawral Resources-Division of Water Rmo rces Revised Aggust v111