GW1-2022-06728_Well Construction - GW1_20220628

WELL CONSTRUCTION RECORD FuTtTermlUscONLY:
This farm can N,It-G d fttr 51nglc cr multip)c t+•ells
1.Well Contractor information:
14,W.A-M1f ZONES
John Eisenman FROM I TO I Dvic'RIPTIONi
U101 Corain7Ctor Norm
ft. rt.
4439A
NC'Well Cuntracior Certification Number I5.OUTER CASING(ror mniti-ca vl srcfls)OR LiKER i If a► rtcabM
FROlI. TO PT,%m:TCR TMCKNESS 31AiT11TAL
SAEDACCO Inc 0 It. 55 fL 6 in. SCH 40 PVC
Cnuslrmy Name 16.INNER CASING OR TUBING'1 eodterrnA ctusatd-lure t
N/A FROM TO OL1htET6R, I THICI{PiM MATERIAL
2,We11 Construetinn Permit 4: 0 R. 65 it. 2 SCH 40 PVC
Mit all agpiirut:le well'ia=mki tlr.Coimr.V.,5M.,e,lbrkzwe,frhre 6bq etr�J
3..NVell Use(chcelmell asc); 17_SCREEN
Water Supply S'Vlll: -FRO`,t I To DIA31ETER ST.QT897X THIC'KtirS5 I 1VrATF.RIAL
4
Mgrkultural ON11ilnicipalipubliC. 65 ft. I 75 ft. 2 in. old Scil 40 PVc
OCToithennal(ileidtWCoolin_,3upply) OResidetitial IN'a(or.Supply isinple) ft. [ ft.
Cllndusoialfio►tlntetcial DResidcntial\VSter Supph'fsharcd) �oGRO[tT 70. ?rATERL►L. I EN[PLACEhI[VT 1fET110D S.%SIOGNT
❑lrrieation 58 fG 3 ft. AquaGuard Tremmie
Non-Water Supply Well:
3 R. 0 ft. portland pour
Do Monitorin' ❑Rccotcq
Injection Well: fL rt
E1Agi ifcr Rcch:ir,c ciucdialion IS.SANDIGRAVEL PACK(it t klicat►te)
.. `FROST _,, 7L) 1L17FRG11. .' F.31P]A('fliF:NT 31t:T►IOn
❑Aoi ifcr Stoittkr.and Re owry ❑5 tltnity 13atiier 75 R. 62 ri SAND #2
❑rCgt tifcrTest ❑Stoema 1tcr�rainage
ft: ft,
❑E:xpi;imcnmI Technology ClSithsidcn c Pn1rol
20.DRILUNG LOG Catlacb additional sheets if PmesmF11
❑GeolltC'nbal(Closed Loop) ❑TrdZC[ FRONT TO DFSCtnPTIONfivbr.bardricai,wiVOKktr :A•sin+arc,cstt
❑G uthennaI(Heating+Coolitie Return) ❑Odter 4ex lain thidr r Ak24 Retnatks) 1 0 ft, 4 rL Silt, sand and clay
4 fL.' 75 R: Bedrock
1.gat w u�s�cnn�pi�t ,i: 35 3-11-22 :WCIi IPI NW- B
.
54 1 U11 bication f4 ft,
Corning Incorporated N/A f4 fl N g
Faeilitg-,"Cht�ttcr Nang Facilit}-TPn(i(applaablc)
3900 Electronics Drive - Raleigh, NC
J y
Plnsieul A44re5s Cin and_Zip
21.REMARKS
Wake County 1715781482 62-58ft. Bentonite seal
Ct+nnl}` NtrC]Id-Oli fu:.11imr No.(PIN) - -
sb.,i:iititude'mnd I ongitndc in ftgmeslminut6heennds rar dechiml itegt ixs: 22.C'crtifratiou:
{itiicll.txlil,rpa.l:tt'lu+;s;is s7rlliC%nt) ,
35.832589 -78.604500 3 13
A° / /2022
Date
6.Is(are)thewcll(s): MPennatit:nt or ❑Temporan' r aLs �" �a
Ih r``. r rf r... +�. 7.,:r 1+.e:.7 tirvurnrer�it:rcrrtrr.ntrr
u•i7it 15. '1 "'tc O,Y na,C.'; t,T•::,G l�.'.L" A'Oti tv"'I Cvnsm+rriat Sraa,lards antd rl,Aar a
7.IN tW.4 a irct air in an ezisti .-vvclli Myer dr 0.No 'o-Vy of rhx3 rer6rif box hen prm4d-4 bi�it 4"•mt-ll rmnrr,
lldl`Ir'ti R reJxtlr,-tjil CdN1`aoitpl btforoh7rhoi and C.t'pbim the novire of rht
rrlrr•irrurderd2l remark:;seciim or rxa the L r,Ck(!(thb form. 23.Site dirigrani or additional well detaits:
You 11ia}.us�.t1tiv.�ack of dus t to pt&ide additional well site derails of well
8.Iiumhet'of Shells construeted•? eonstmotioii details. You in4v also atiacli'additicttiat pabk-s if mecessaw.
For ittiilfipie igeerltm err nevi=reaiee nipid),wolfs ONLY idrit the same carrrstruerearr,_;:cE+Catd
.m0 irmi fttrv,?: SUBMITTAL iNSTUCTTOl1TS'
9.Total well lepili belovi land StirfaCe. 75 (fl.) 2aa. For All 'Netts, Submit itnis fomi -within 36 dot's of compleflon raf'dell
For grube'my welft list rdl drjnlrr tf dUV'r4'au(e.T4 n1.,fe-'3eD-'09'tu1112@ JfN) -conslmction to Utc fol1m ing:
10.Static water level below top of casiii ((y,) Division of Water Rescums.Informatinu Processing Unit,
1f uu;rx res el is abdee rastar,,ose + 1617 Mail Scrs'ice Ccnier,Ralci h;XC 27699-1617
It.Borehole diameter.12/6 `(in.) tab. n 11N�-fl!ad%l c ONLY: In addition to sending eli:form to tb6 address in
�'4aab+tii'e: also submit a copy of this fr)nll Stilthin *0 days of CUIIlpleti6o Of %wil
12,Well copg 7tetion method: HSA/Air wnstmction to the following:
1'i.e.Sager.r us}',cable.direci ruslC etc.i
Division of Water Resonrc6,Underground Injection Control Progr.un,
FOR WATER SUPPLY WELLS ONLY, 1636 Mail Scrcice Center.Raleigh,NC 27699-1636
13, Yield();pm) m ltoil of test.- 24c-For Water Supply&Injection Welts-
Also Submit One colt' of this fbrlir 1t'ithiti 3w dat•soicomplelioe.of
IJh.llfsintlYtlnn npc: Amount well constniction to the county 1161th deponmem or the cmim irlwm
cps>SintoEed
Fenn G%V-t l onh Carolur:t Elcpansikicnr of E.-Mmminciu ami Minn-J Rewarces Uiviiion of A'alcr€mo ran Rot iced AL%L t-N?L4
I I