GW1-2022-05488_Well Construction - GW1_20220601

WELL CONSTRUCTION RECORD For Irccmrl Use ONLY:
This form can be owd fm singic or nusbipk++ells
1.Well Contractor information:
14.WATER ZONCR
John Eisenman FROM TO DFS(,'R1Pt10-i
t\'c11 Ct+nar(gor iaftK
N. ft.
4439A
NC Well Comractor Cenife anion Nunbcr 15 OUTER CA#1b1G fdruiuhi-eaird ncns OR L1NTr.R 1 i IkaAk
FROM TO DIAMETER I TIIICKNFSS 14ATERtAL.
SAEDACCO Inc
f omp,m),Name 16 INNER CASING OR TUBINGYjeoibermat clused4cwti',
FROM TO DLA.METER. THICKNESS MATERIAL
2.Well construction Permit 4: 0 ft. 5 ft. 2 I t• SCH 40 PVC
l ixt all applira6le well pr'13rritl ri_r.(minty.Skee..Variance.11tr604 ew.) fL fl. m•
3.Well lisc(check well use): 17 SCRUN
Water SupplyW01: FROM I To I MANIFTER7 SIPTS173 THICKNFA.-> I MATF.RIm.
0Agricultural 0Munkipal/P)Iblic 5 A. 15 R. 2 i^ ' 010 SCx 40 PVC
OGeothcmlal(tiC11in&C0oling SupphV) OTtesidential Rater Supph (single) ft• ft. in.
dlndustrial/Conlmerciai 011csidcntial\Niter Supph•(stored) 18:GROtfi
FROM 1 TO MATFRIAI. I F.MPIAC'r:M"T MFTROD A AMOUNT
❑irfi •Rion 0 It. 3 fr. Portland Pour
Non-Water Supply Well:
tt. tt.
®Monitoring ORccovcty
injection Well: A. iL
OAquifcr Recharge 06roundanier R9mcdiation 19.SAND K:RAVEL PACK kabk
CRltrl I I MATVRLAI, HMPI \CY:\IE\TMI:'tf1O1m
❑Aquifer$torngc and Rccovcty, ❑Salinity Hamer 15 R. 4 ff. SAND' #2
13AgoifcrTcst OStommatcrDriin,aF,c it ft
OF.Vcdmcntal Technology OSuhsidencc Control
20:DRA.IdNG-:40G fatlrch addilionnl aMetsif nceaoan
i3Geodrennwl(Closed Loop) OTracet FROM TO nFSCRIPTION((*Wr.hwronci:011'htrkl+ -n.tve.W.)
❑lreo(lrennal(Heatine/Goolin2 Return) clother lex lain under 421 Remarks) 0 rL 15 ft. SANDY CLAY
ft. ft.
4.Date Well(s)Completed: 5-18-22 Well iD#KW-3
fl. ft.
52.Well Ltleath)n: ft, ft.
tt. ft.
Factki /O%vmr Nun+c Facilht-IDN(if applicable) fl. ft.
Mel LIM
610 Lakeland St. Durham, NC 27701 Durham County, , ,
Pltysical Address.City,and Zip 2I RI DiARIC4°:
bentonite seal from 3-4ft
(anrtly Partei bkalirr-11ionN(i.(PIN)
5h,Latitude and longitude in degrecs/minutcs/scconds or decimal degrees: 22.Certification:
(tf well field,One 1:11,961ts is mt icwtn)
N N' ' r 5/20/2022
Signatory of 1 \ .'i k o !!e^ c--- - - Data
6.h,(are)the wcll(s): .WPennancut or OTemporary s `/f � vier N �s `�� "�a��
h)= ignit•g this otr rl t. qC 1 eaartrtrcred ra aecortlanre
idtlt'14A NCAC 02C a/ 4'�F C A4-WC.0209 Well 01nstnn3imi Sratkl(trdb(rood tlgrl p
7.IS this a repair to an eai%hDg well: OVes or allo rfy)t`(rftlik rer4ml ha,1 been pntt'ided'tn the mr1l(At•ner.
1f this is a to pair,fill(xtt toot iv ierll consipurtinn hifnrtwthm and a plater the nature of rhr
retmir tnrder$21 remarks.srruiem nr cvt rhr hwl-oftlric form. 23.Site diagram or additional well details:
You may Ilse the back of this I)age to proxide additional well site details or well
8.Number of wells constructed: 1 coostluction details. You may also attach additional pages if oecessaty.
For.malrVe fnjeerkm ew eum-water smpp)v it-,ells OjVI V nNhlr(he some ronsrsection,ycwe r(rn
xvhnrir oar fora. SUBS11�1 AL[nrCT�1C.TIONS`
9.Total well depth below land surface: 15 (ft.) 24a. For All Yells: Subn»t this form within 30 days of comptetion of++Tit
For mrdtityle wells liar all depllar ffdifferew lexmnple•,i@lW aryl 20,(Ike) constniction to the follo\\ing:
10.Static water level below top of casing: (ft;) Division of Water Rtesourem Information Prucrs.4ing Unit,
1fismrrlevel is ahme rasing,9se"4^ 1617((fail Service Ccnfcr,Raleigh,NC 27699-1617
11.llorchole diameter:6 010 24b_&1 Jnl%x9 ;ONL'': In addition to seitding(lie fomi to the address io
243above. also submit a copy'of this form within 30 days of completion of well
12, %'ell constnlction method: Air construction to the following'.
(i.c.auger.rnaan•,cable,direct pssh etc.)
Dh•ision of Water Rcsoumes,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC27699-1636
13a 1'idd(gllin) 'Method of test 24c For Water Supply&Injection Wells:
Also submit one copy of this fond within 30 days ofconipletion of'
wcll constmction to the county licahh depwimcln of the cotmh-wherc
13b.Disinfxtion type:,_ __ Amount:
constructed.
Form GW-1 Nonlr Coinlina MWrintcnt of En ironinou andNain al Resources-Division of(Pater Resotroes Revised August 2613