GW1-2022-06371_Well Construction - GW1_20220628

tab'"ELL CONS'i'RucriON RECORD For klental Usc ONLY:
This form on ba used far single ar multipk hells
i
I.Well Contractor Information:
14.WATER ZONES
John Eisenman FROJ1 1 To, l DF-ScRtFnON
Well Cormm5le_r'Kanu, ft. ft,
ft.
4439A ft.
NC S4cll C6ntr,IciorCcdiftealianNwr-ucr 1i.OUTER CASING(for raulli-easit5l areflsl OR Li ER fit applicable)
I TO I Bm mxTrn. THiCKNESS NZATERTAL
SAEDACCO Inc 0 ft, 47 (L 6 in SCH 40 PVC
L:aurp:uq'Name 16.INNER CASING OR Tl'BING -ache mal elused400
FRO51 TO DL_.%mYTl?R. THFck:E55. I MATErtUL
2.WCII C@nStrui irlpil Permit R: NSA 0 R. 50 (t: 2 ' SCH 40 PVC
Eit all r,JTlicable well prn vfrr 0-e.Comm.,.Searm,lrariatire.74aciYen rn.)
r I,-
ft.. f4
3.WCU V,k(chocicovcll tisc) 17.5( I
Water SuppLv Weil FRQN3 I TO I D1:t11F.Tr:R S LOT S17T. THICKINESS I MATERIAL
fJA�ricultilral 11MunicipaUPub,ic., so ft. 60 fL 2 W6 old SCH 40 , PVC
Io1Gco(itennal(HeatingiCooling Supply} bResidential Salter Supply(single). ft ft. i�
0lndusitialJCommucial DResideutial Water Supplly(shamd) 18.GROUT TO. ?LATFRt tT I EA[PIACE\tLNT\iETiIOD S Ab10ltNT
❑hiiautinn. 43 (t. 0 fL Portland Tremmie
Non-Water Sol ply Wlell: rt.
&Njonit6ring; ❑RCcm•cry
injeclion}Nell: rt. rL
ElAgquiteFkctfiare vs-a rRgiwdiatipn t9.5.lNb1Gt1►lEL PACK fir ,Ii DtY)
'PROTI ..�T¢ 11 ATERUI L. ,-F:MPI:A(`MTENT EMI(r It
❑Atjnifgr..5ttirt�c9l(li#cm'cm Qs9tnity 13-a- lcr so ft. 4s ft. SAND #2
❑AgliifeiTi;t �J*rInwitcrOpinagg. ft.. ft.
❑Exp,-dmcntal Technology '0$nb5idcacc Cdrnro1
20.DRILLING LOG(allach addiflonal sbceis if treeessarl•I
116totllenhal(Closed Loop) (]Trdt Ct FROM' -T[t DESCBt[P170\reabr.>ardnc*i,vwii'nxRty t+ri�xie.ilr l
[]a-odtenital(Heatini,Coolitie Return] 00dier(e_r lain•dirder 921 Rrtdaal,), 0 (L 3 fL Overburden
3 -ft.. 45 (t.' Saprolite
4.DatCytrell(s)Con tpleted: 2-17-22 epin c MW-33B
45 'f►: 60 (L Rock
54;%W11 l:ileathiu:
Corning Incorporated N/A
rL. rL
Fueilii},C1lrneryanc. Faciliti iDR(ifappli able? i
ft,3900 Electronics Drive - Raleigh, NC klnl:
Iriivr : 3,
Pll�sl^a1 +ldrass City.snd,Zip 21.1iE61AR1i4 ✓ r "`
Wake County 1715781482 Bentonite seal from 48-43ft.
(�rnruly' Pdn:r:]1rJ:nli[LG11inn.Na.(PI_Nj
Sli_i altitude anil7a n itudC in.dCRmccliuiut tt;lscciintls rardecimal'dcbr`mst 22.Certification
(ifecn,tsCfd,piic lai9pug i SrcJlicic�d}
35.832589 -78.604500 4`;' ? '`~ --- -=- 2/18/2022
6.Is(ari;1 Weti�cll(�}: �Pennaraent or i7Temporiri'
f1z signi,l�r�,s futia rf ti,�.:. , 1»u ,r..t: 7 zvr�lrurrtrl irr r�xarrmece
?viilf 15.I XCAC 02 n.-.-..,A7.0A39 Hre?1 Cuiisrrordent Srr7rptnntsand rJrt d
7.Lc this A rcli3kfo an Lxkting;"-Clh Dyes mr END r a%pf rhts magi,if ax.&�r+,rira;ru1,4 r�+1. girl!mv;u•r,
if ibisj.3 a 41mir,,�ill m, Orr;iryr r+rltrcrrurnrcrr,r,i1rPtxQr:on and ex lobi rJ,e moire of rlie
re,,r,,r rr ;j;21-rernarJL;.rectiiiir.orC'M flit! .23.Site dhigr•ant'or additional well details. -
Yau iui}_Iasi-illy Back iif diis p tu-protivde iddilollal well sile.detailsor isll
8.Number of ii•ells.evnstritcted• 1 construction deiaits: You.mav allo_auaclradditionil plbvs if irmes"sali`.
Fvr iita lrlJ lr dire°ilun ar er.Ni-7r rrcr sop J}rri`la ONLY--il-SO rhr srrrile erura�urlFnJr._gt..,Crux
,stpmfi crow firm, .. SUBMITTAL-iNSTITCTTONC-
9.T0tal.TWell.depfl1 below lA d stirfu i*; 60 (fY.a 24iL For All.Wclkw - 4u6ridi this forin within Ri'dars of comptelion of Bell
Fvr?gt,lrTntt+i.,ells l sr rrtJrJ,•tvhi rj ciir i•re,I,(e r„rn fr-.7r,�7f1i`u,uJ ntl i'> ConStinctipn to the fbllaninjgr
10.Static water level below tap of casiuW. _ (fL) Division of W2tcr.itesadrees,Ilaformution Prilcessing Unit?
1f vivet leprl d,ttNoie crrsirtz,ose + 1617 Mail Ser ,vice Ccnicr,RileighINC 27699-1617-
1 L Bnrchole diameter.12/6 (in,} 24b.For TrijU.fiol L1 Iv-ONLY: In addition to sending.Me fowl to the address in
24da6ke. illso submit a copy of this form within 0 days of.cainpletion of kwil
1I.t;cell mustmetiou-method; HSA/Air Lonsinictiuti to the rQuoNvir1E:
(i.e.au gci ijz�%%wblc.direct push.etc.)
Division of Water Resoum,6,Underground(ujecllon Contiml Progratir,
FOR WATER S LIPPLY WELLS ONLY: i636 ALail Service+Cenler,Raleighi NC 27699-16:36
m \7cth911 of IC55t• 24c.For Water Supply4c Injectl6a�YC1I5:
13.> Yield iS9i. ? Also submit one copy of this f6fr11 t1'ithill +ci daysof.compleli6rt of
13h.DiAnkttion type: Amount- well consiniction to the county health department of the comity where
constntc(Ctl.
Farm GW-t \unit Cawlun Depari=nr of En%iroanrm;fl:d NIaursal Resouxes-Uiviiiuu of WalcrrRFM ra-- ftci ised Awgust h?I