GW1-2022-06732_Well Construction - GW1_20220628

WELL C0NSTRUCFt0N RECORD Furitunt<alLrwONLY:
•11ES form can N1 used rcr sinric or inullipk lseils
1.Well Contractor inforutation:
14.WATER ZONES
John Eisenman FROM Tt7 DFSf7tlPilti�
W01 Cmm=w Nanis
ft. it.
4439A
NC SVell Ci,ntrlclerCcnificaiionNturiier 15.0[iTER CASING(for multi ea!ed e"ellst OR LINER f it a Iie:able)
FFO`I TO P[.�1iETFR THICti�tE55 MtITEAiAL.
SAEDACCO Inc ft., fL id.
t:an�r:ury.Hann .16.INNERCASING OR TUBING'f uoliferival closed4ou '
FROM TO DLLVETult InlI NES5' MATERM'
2,Well Constivetien pel•iirit N.. N A 0 ft. 24 ft„ 2 SCH 40 PVC
1-fir 411 41711rfs61e a-r!!pnmlri(ce.Gnv,nc Sl rtr,1 uriurrr,Ir}`�a7rg1 rlr.;)
ft.. ft.
3.1Weli t sc(chechwell use): [7_SCREI N
'Water Supply Well-. FROM I To bl:\MMft ti1.OTSUT TMNQi5 NATF.RIAL
❑Agricultural C114ftinIeipaleNblii;, 24 ft. 34 ft, 2 un. lnO10 SCH 40 PVC
CtCeotllerrllal;I3eatitttttCoolitL ripply OResidential WmerSuppb,(sin lej fi. fI- fin;
QlndustrialfCoRutlercial DResidenEial Watcr Supply(slxll d) tg,GROUT
FRd3[. T0. SLtTEML- EAtPL-,C MINT 1[ETiIOD&..MOUNT
Qlrn '[ion 18 ft. 0 fL Portland l Pour
Nou-W;lter Suppky W4 11: 7e.- rt
�dhippitprin ORcco�-ct}• -
injection Well; n." ft:
❑Ag1t"itcr ite4h trgc" ICit�uDd ItCr Rgiiic[lietipti t4.S'.41Vb1GRA4EL t•ACti it tllc�lltc)
't�ROM _ 7(7 ",V ATFRtlll• VAIP1.RC"IFNT NtirnQn
QAgiiifCr Swr tgu ai1E1 RceO�up" P!Rjlinily Bardre 34 ft. 22 ft. SAND #2
❑rlgtiifcrft t ❑St+7snlisatci Di�tij,gge
ft:" ft.
❑bgl;cimcnhtITwhnoto %, ❑5uh5ids:ncz:CnrAml
10.DRILULNG LOG(attach additional sheets if pmessarr)
❑5mhenixtl,(ClosedLuup.Y []Tracer FROM .70 Do5clurnoN,(mbr.wrjiico,iummck sy pc,' on�we,dG1
❑Goothe inal Meaiinb'Cuolinp.Retum) QOther t>_cplain ulider.#21 Retuad s) 0 ft, 34 (t saprolite
4 DafSVrlt(s)Cuutplidetl; 2-22-22 W'elllD#: rlw-39A
Sd.•Well IAcatBtln: -ft. f[. jUN L
Corning Incorporated N/A
ft," G Irl „ C� ?t4:•;FS:{ t5 11nil
Faciliiy'JCllrer age Fxtln.iP (iEappli ible}, �;3:11Q/ci0G
3900 Electronics Drive - Raleigh, NC ft. tt
P.lrysiegl Plddi s�City.and Zip I'21_REMARLt'S
Wake County 1715781482 Bentonite seal from 22-18ft.
cnrotl Fslrecl It>:AIric:piau No'.(PIN) I
75b.LiWtudc and l�ngitUd�iii�Bcgires/minutcslsecn11 or ti�cim[I d�rcrsc, 22.Certi£ceatkih:
(if15c11"IiCld;mu,-I•urtuti issirc`i6d)
35.832589 -78.604500 N ��, _ 2/22/2022
Si;n7t9m_of. ;:' ry"ll1v.-0.- Daic
6.Is tare)the wcll(s): MPermanent ur, OTesnporarx'
Ih +�yriri,�,i.0 fgl,r of _ r , � t+x r ir�.�lruernl err-rrc;a•�rr.ancr
iviiitl5+tNCAC,ilX-: WeefCi:nitre,rdoirSwov!ardswidrhyla
7.Lr this a i mii to an eustin't,welli ElYrs or "®No rro. nj rfr7-3 i orrf hrt.••ht'ar p'nii-414tj r.yi6.7 5`!t"rnrijer,
ljrht 'fs r rc}xrir,611 wir kaoite, crrd explabi rbv nur.,re,,fMe
repairuti derd2l reenurlLs:declrma or rsa Ma hri.(of rfmv orm. 23.Site diagrain or additional well details:
You 114'use the beck of"thls paw to provide additional well site.details or well
8.fiutulier of wells consiritetid., 1 coistnictiuil tleiails. You inat`a-bo:attacll additional pages if becessan;.
For xtarlrlfWc itkerhm ot'rir.4i=netrrr ntpp4l lq, f;t}N Y tvlfft flit,some carilstrltrtfwr.,;;net"Ceto
r unt8rrfirjnrev. SURdiITTALiNSTUCTIONS'.
9.Total well depth-b loc,land surfuee�, 34 (ly,) 2aa. For All Wells, Suhntii this fo'rui wilhin al"d3xs of completion of well
For rtt+hipfe n-ri'fs hsl ad fiv#hs rjdrfper••ni(cr rn,plc-;r<<_t10°iritrl3F f1 Yl constniction to Ilic'fplla%ing:
I0.Static eater level h'elow top of casing;. tftj bh'i.+iun of Water Resources;Information Processing Unit,
!j',t,aier h-vr!!,above cusiug,erxi"+" 1617 Mail Service'Center,ILilei„h,*IC 27699-1611
11.Bni't 11tY1C dlatsictei 8 tin] 216.Fnr iie trctintl LNCllc ONLY: IR additionto sending tha fomt to the address in
24a kove:.also subDltl a.CoMr of"tliis.fanu within 3Q dat•s of completioll of.well
12,Well constmetiou tnethod: HSA CC+nStlllctltjl4 to-the following.
(i.e.simcr.fD9nv,cable.,direct ptisK cis.}
Division of Water Rcsourres,Underground Injection Control Prograin.t,
FOR-NKMR SL'PPIL WELLS ONLY: i 636 NIA Service Center.Raleigh,VC 27699-1636
13-. Vicid(9 Method nftest, 21c.For Water Supoly dlt Injection,WON:
Also submit ow eo)y of this fiinv tcithin 3o dat•sofcumpletionof
wetl constniclion to the coon}iteilth departmmit of ttte county n-lierr
13b.Disinfection hpe: Amount: eclnsln�cEed-
Fdnuaw-t \icRtrCarvlutaL4pinnsenrofEtn-irorurimtandMrmwnallewwces-Division oftValcrgrmowcm Raiiscd?,tt d29I:1
I