GW1-2022-05931_Well Construction - GW1_20220627

WELL CONSTRUcrm RECORD ForlrrcrualUscONLY:
•fhs.form can W.uwd for sin(acormultiplelrctls' '
1.Well Contnlctor.Inforination:
14.WATER ZONES
John Eiseriman FROM TO DDWRIP110N
%V01 Cul•ertctor Nano
ft, f1:
4439A
NCWcllContmclorCcnifrcationNuither 15.OUTER CASING(fornuilk-wdxeflstORLINFRlifa IlcabkI
FROM I TO 11xmcTER r '. TRICKNESS,. MATERIAL
SAEDACCO Inc 0 ft. 110 fL 6 in. SCH 40 PVC
C'010V;Lfl:Namr iii.INNER CASING OR TUBING 42tudwrtr21 clu5'cd40wgl)
FROM TO DOMF.TER THICKNESS I MATERIAL
2.WC11 Construction Permit fl: 0 ft, 115 0— 2 ilL I SCH 40 PVC
l i+r uf!trjyilirrrf lc uvlih,iirrirr(i_r.Ennnty:Stu:c,lGuintrcr,Irl`atiq;rrc:J
It. ft.
3.Wei 1.[;sc(check well D5c):- 17.SCREEN
Water Supply\\it'll: FROM I 'TO I DIAMETr•R: St.OT\fy)_ TnIC1<\Y14 1 MATKRt,L1.
DAgiicultural Ghf uiicipaLTuLfic :Lis ft. 13.25 ft. 2'' in• 010 SCH 40 PVC
I.3Cn*atllemlal(Fleating Cooling,Supply) 0Rcsidential.Writer Supply(single) ry fl. In
Ohidustrial/Conuuercial ORcsidential Water.Supply(shared). 18•GROUT
FROM I TO MATERL\L 1 E%IPL%C7.MLNT.Sl )too&AMOUNT
Ofrii aUan 110 ft. 20 (u. AquaGuard ITremie
Non-Wafter Supply Well: 20 R. 0 ft. portland I trelDie
❑Monitoring 011ccotrn
Injertlon;\Ve1L• n. r4 I
QAquifer Recharge ❑Groundwalcri(cincdiation 19.SANDIGRAVEL PACK tit t fit
FROM 10 MATERAAI. EMPIACENIFN'T b1E:Tt1011
f Agnifcr.Slorigr ani Rcco%'cr}. QSalinin 13arricr 125 A. 113 rr. SAND #2
❑AquifcrTest ❑5sormwatcr Dmina^c
- ft. ft.
❑E.lc6mcntal Technology l7Subsidcncc Control
20.DRILLING LOG tallach additional stunts if ncccewrs'i
❑G othemul(Closed Loop) 07fricer .FROM To DF,SCRf@ TIO\(cabr•t nrdnca,r.n'nK4 h s u,ih•.tM.l
❑G:olllenlul(HcSiing+Cooling Mum) QOther(explain un&—r P1 I Remarks) 0 tt.. 35 if. clay/ sand
35 ft, 52 (t, Pwr
4.Date Wells)Completed: 5-12-22 Well iDsMW-16 52 H. 125 tt. rock
a
Sa.\/`CllLAcation:' it. ft
- .
022
Facilily.-DwIner Nanv Facility iD"(if app5 able) tl.. ft +r �- s.s:,
lnfcrrTaU,,, ! Ic•C,n q.IFJ Unt1
3767 lioywood Rd. Graham, NC 27253 .Alamance .County, , , It.
Pin s+ciil AJdress.City.and Zip': 21.REMARKS
Hentonite seal from 113-110
Conuq` Rircel Idzilli ftcaiiou No.(PIN)
Sli.l:ihtitirdc anil I ojiigitude in drgtres/minutcsIscconds or decimal(I rocs: 22.CcrtificatioD:-
(it%wil I"!`Id,One lat+luo;is xidlicinil)
5/13/2022 _w
6.is tarn)the%ccll(3): 70Permanent' or QTenlporan
- Ij1.17.5+IU.n.1(11.u+.... !w 1••c..• ,:t.ty5'frac'![il iR QL't'OrGfir!(Y'
u h 15A NCtC 01C ;;UC A109 Well Consfrr+rrion SrarkIaMs wullikil(f
�.1s-thbi a repair tD an existing well: MY6 'o' _CCNo On lir��!>rrn hr.�ritl,•�l rn-:hr'str11 mrn�r.
if this is h i7xtlr,fill cerr known wolf cony m l ar ialurrurrirnlm+rl rfnlaln rlre•ntrrure•of rile
rrlarirrun+rr�21 r-rnar&s scnian nr cvt rltc 6 ^S'of tilts fsrm. A Sitc'diagr4m or additional well details:
you niay use like
hack of this page to ptoride additioiutl%%•e-11 site details or well
S.Number of Vvells constructed: 1 celutluelion det 1ils.-You uiay also attach additioi l p ges if it Cessar}•.
for+ntdlilrle b7jtzf all or orn•l-irare•rsupItly bells nNLY wirfi r1w soniecunstruclior,cnu enn.
.+ub+nit S(AMITTA1,((\STUCTIONS
9..Towi ii ell depti.,befoir"landsurface: (ft) 24a. For All Wells: Submit this form:wilhiih 30:days of coulpiction of Bell
For 11ntlliple.wells list1711dec ibsifdifi•re+irl�.Tiw+;trlt-?c:0!Pcuufi@IAdT• constroctio616ticfollouing:
10.Static%►ater,lcvd.belu»'cup of casing; (ft.) Uii•uion of Water Rcsaurces,InformatiDD Prvicessiag Unit,
if it-wer 11•t-16-e:b,me cailhrr'ate••+" 1617 Mail Smice Center,,Raleigh,NC 27699-1617
11.Borehole diameter.12/6 (in.) tab. n i l�ONLI': In addition to sending tic form to the'address in
24a abot'e. also submit a copy of this four within.A days of completion of%tell
12::\Vell construction method: HSA/Air Construction to the follo%ving:
(Lc.auger.im*,cable,disci push e(c.)
Division of Water Resources,Vride•gronud fnjecton Control Program;
FOR WATER SUPPLY_WELLS ONLY. W6 Mail Sen•ice'Center,Raleigh,NC 27699=1636
[3a 1"told(gpm) !►7ctbod of test: 24c.For Water Suptily ti'inicdlnn Wells:
Also submit on _copy. of this fon'ii.lrithitt 30.days of completion of
13h:UiaiafiYKiiloa pea amount veil construction to Ilic calmly 1lcalih dcpartnuntof tltc county11-licrr;
constructed.
Form C V.-I Nnnti Carolina Mpanwent of Env iromtrm altd Natund Resources-Ui+sion of Water Rmotrcm Rcvised A gust_1013