GW1-2022-06738_Well Construction - GW1_20220628

WELL CONSTRUCTION RECORD For lrkcmtlUs,;.ONLY:
This Form can he aced frtr single or mLd ipk lvells
1.Well Contractor Information:
I&►►i\TER ZONES
John Eisenman FROM I TO 4F-5(-RKv A)\
tti`cll Ctu�rtcior N�nw fl. ft.
4439A
NC►yell Contriciar CerlifiotioiiNtuti)rr ti,OUT1iR CASING fur mat11 ca and wd1sl OR LINER tii a flca6kl
I Ni OU TO DC•1 ETFIt. Tn3C1%%ESS NIATERiAL
SAEDACCO Inc 0 (L f 108 (L 1 6 in. I CH 40 PVC
Caliv."tl'Nante IG.INNER CASING OR Tl1BING l onberro:il cirri ed I Ott
FROM TO DMMETER. "MICK,NESS I NIATERIAL
2,Well Construction Pel'ma n: N/A 0 ft. 116 A, 2 in. SCH 40 PVC
Irsr all q),311rraHe v.elf pc'nrrit s(f.e.i7fju tr}•;Stiih'.Varfarree,1r.,y'eCiYCn eir.
rt, rc. in.
3,Well GsC(Chccl:Nvcll use): 17.SCREEN
WaterSuppl�%yell E
• FRONT TO Di,%NFFTR SI.OTSI7F: Tillcus1SS I MATERIAL
LaricuItitraI 014tinicipal;PRbliC. 116 ft. 121 fi. 2 iR 010 SCH 40 ' PVC
0A
06cothennal(t3eadngXooiitT'Supply) i 11t.,sidcntial"Water Supply'.(single) r►. rt.
❑IndustrialTo"MICrcial ❑Rzsidt:ncial t►rater Sgpph-(slrtit;d) 11 -GROG TO Sr,\THltt1L- I EN[PLkCE\TENT 1rCn1011 A AMOUNT
❑lrri ation 0 ft, 1 110 (L Portland Tremmie
Non-Water Supjll}'W.01;
5dlvionitorinG ❑Recovery
Injection Well:. rt. rL
[]Aquifer Rccht3,ti;e 00onndnmcr Rcinediation 19.54NbIGRA EL PACT:tit r oHL-AI gel
F•Rt)NI _ 10_ _ .1L1TMum. VNIP1.AS`-INVE.T N11711 n
❑Aquifer Stt?ragc and fteco'Cry ❑.S7li11it<•BaMi qr: 121 ft. 114 A. SAND #2
❑AgitifcrTcst ElSfoelnlratcr 13nttnagq
❑Exp.-rimcnialTechn6togy ❑SuhsidCaccU6lltml
20;DRILLING LOG fattach addiflonal sheets if necessarrl
❑Cr'ptliertnal(Closed Loop} OTrjeer -FRONT TO DESCRIPiiON(iv oJuird"evi.�Aklmckli :o4ifi.we,CkA
❑Geothemtal(Aeatinp-Cooling Return} ❑Otlicr tesplain Linder#21 Remarks) 0 h. 5 it. Sapiolite
5 (t.. 85 ft. PWR _
4.Dati%11(S)Cutliplcted: 3-25-22 ZVclliIl MW-36C 85 li, 121 f,4 Bedrock ' i` ^ic°
d », ,
54 1V111 ia1Cattrin: ft f4
Corning Incorporated N/A jUN R; fL `J
Facilitti3OiYrlcrNamc: Facilijy!Dm(ifappjkablc?
3900 Electronics Drive Raleigh, NC ft. rL
P1n ikwlAdi k City.acid Zip 21_RERtARIC.S
Wake County 1715781482 bentonite seal from 110-114ft.
f"rotor?' I.1n:el M4:3difiGttiunNa:(PIN)
5b.Lmrtude acid Longitude in tletirccslminutC3?seconds n"r:dr:crmal.tt.Cgrecs: 22.Certifteatinn:-
{ii'sscll fxlrJ,tJtrL.la4 lut>L is SrclliGr`nl}
35.832589 -78.604500 4/20/2022
Sig ntciz�"a f ':_:k �3t ;E��+ay;:`——r-_ Date --
f_-
f,.Is(ire)Wer�ell(s}: EPennanent ur IJTeugwratl'
- Ht'signii+g ti.�r(o..+r,, Y". - uf�.i,+...."' J taE:a tvr_5'lnrcrnl8rnxrevrr.4rnre^
R'ieit 15,1 rVC,1C•02C.1 -1 1 i_C, -;;ti.020P IVe f C'r iisre,Jr'ife i1 9rruirlerf&zrnd'r1r,14r
7.I_e this arepairfoanexistinl;wcili EIV6 nr MNo �nfn'ofrja'rr"rrrifhrr.Yhven'pmvir++r;roibe..,n-11wner.
f/tf,ia'1F i2✓-erxtlr;JJlf dh•R 4rV+sA IseJfe'Q7JSJJLe lrtrJ HtfUrtl4rriL'rl ateJ(r i�s'y7irllit r11Q JI+Irtaf£n/rl�e
rr+acirrctirler11?l irutr;rk.Ys.°rJrarr or an f&burl l 23.Site diaigrant or additional well details:
you niay.use the back of this gaga.to.p ovide additional well site.details-or hell
S.Number of tr'ells constructed: 1 cwnsituction dxtails. YOU inaV also attach additional pages-if necessan•:
For+atrfrilVe iaJevrltvj ty rjoi-iraier ilipr y ivi'Us ONLY ivirll the Berth crtitt6tPRCrlvtt,-'k:tt Prit
.Y.v0nrirr9Jta frirnv. SUBMITTAL iNSTUCTIONS
9.Totalil'el[:depdi belays"land surfue! 121 (f6) 24a. For All Wells: SO di This f6rul within R, days of completion of iwll
Fop mr+Npl e i.rffs Hct reU defW.0 ib•dii`ei'01J constiactinit to the follolti ng;
10.Static water level belotr'top of casill;: (ft.) Dil-siun of Water Resaurces,Iotormatinn Processing Unit.
If+rater level Ls above cam'rJ.w,tAm"+" 1617 Mail Service Center,Rileigh,NC 27699-I617
lL Borehole diameter.12/6 (inn 24b.Vhj fit fge iigamLk ONLY: fn addition to sending Ilya fonlr to ibe address in
24aabme. also sabmit a copy of this fonn witliitl 10 days of completion of wall
11,Well cortAntetion method: HSA/Air ronsimciion to the follctuvi�:
fi.e.auger.re asy,cable,dim-d Fusk cic.I
Division of Waier Resource&,Underground injection Contml Proa,t-Am,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service tCenler.Raleigh.NC 17699-1636
i
13;L Vicki(gpm) 1lstliod of tc.5r 24c.For W:itcr Supply&Injection Wells:
Also subrnit.one eolr+' of this foam; within +tl daysofcomplelion of
13b.DisinfLetion tv C; . Amount: sceil canstnletion to the connry health deprinnimit of the canniv tubers
Ciln-SinlCtCd.
Fonn Gk%1-i Ni;rih Camlina 6.Y;.-p RX111 of Envirarureas aitd Nautral Resources-Divvibn of Vnicr RL:oucfs- Revised.A gass__M.4
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