GW1-2022-06739_Well Construction - GW1_20220628

WELL CONS'CRucr1ON RECORD For lrwni.•ilLrwONLY:
This rorm can W used f,r single er rrrullip)s wells
1.Well Contractor Information:
1J.W.A.' RZON1S
John Eisenman FROM ITt1 DF-SCRIPriON
%VC11 Gt r rie7er Aanw fl. fl.
4439A
NC Well Contractor Certification Nni ber 1 15.OUTER CASING(for mull ,used riellsi OR LINER fN a FNabk)
FROM To DIANTETEn Tin"NEss NI%TENT.M.
SAEDACCO Inc 0 ft, 1 195 rl. 1 6 ill. SCH 40 PVC
Colrgialy N:1111C- 16.INNER CASING OR T'BING('aslherrnal closedautr i
FROM TO DLAUE.TER THICKNESS I MATERIAL
2.Well Construction Peimiit#: N/A 0 Rt. 1 200 ft. 2 irt. SCH 40 PVC
lift afi ciralli-able WeNPi'-M tr ri_c.Clowir:.Twe,lviriaccr.ITEC6aq ex.) ---'�'
ft. it,
3.Wcll Use(checicw0l usc): 1 17_S(,REKN
Water Supply Well• I FRONT I TO I 11MMETF11 tiLOTS17Y: I THI(7liNF15 MATERIAL
0Agricult1R11 014unicil:QL'Iiltblic 200 ft. 205 (1-1 2 in. ,010 SCH 40 I PVC
t�Geothennal(licatinl,�iCoolin.Supply) 011esidemial WaterSuppty(single) (t I fL in,
❑hidustriallConimcrcial DRcsidcntialIVatcrSupply(staILA) FRO ROUT TO MATERIAL I ESIPL(CENtI'_NTMETnODSAMOUNT
❑Irritation 194 ft, 3 ft. AquaGuard I Tremmie
Non-Witter Suplil}'Well:
3 ft. 0 fl. Portland I pour
6B>vlonitoring ❑Rcctrt-cn•
Injection Well: ft. fL
❑Aquifer Recharge 00roundiwa4cr Rcincdi;ltion 19.S.4NW61 A IK VEL PAC of a hlicable)
'FRONT �Tn N1r ATFRIAL FNIPLiCEMENT%D-1*11011
❑Aqui(cr 5tonagc and Rcr.-kwcry 175ilinity Barrier 205 ft. 197 q, SAND #2
❑Agififcr Test ❑5torrnwilcr Ilrtin,,199
_
❑Experimental Technology ❑Stibsiden c CulatPl
20.DRILLING LOG(altach adtlifonnl sheets if nreessnnl
❑G,btltennal(Closed Loop) ❑Tracer FRONT TO IDF_5CRtPTIOr r,obr,banlrica,,.i2'nKkh t ri wc.atGl
❑Cnotllennal MeatiuLp'C'ooline Return) 1:10dwr(explain tinder#21 Remarks,) 0 (1. 5 ft. Silt, sand and clay
5 ft. 77 (L PWR Sa rolite
4.Date Wells)Completed; 4-11-21 Well iD# MW-18D 77 (t• 205 fl Bedrock
U Well.I.Irea_tion: ft, (L.
Corning Incorporated N/A ft. rL '
Facilily,`C)vn;rName. Facility 1Dk(i(appli ablc) ft. ft.
3900 Electronics Drive Raleigh, NC ft,_ Ft. w
PhisiculAddress City..andZip I
21.RENIARK.y
Wake County
1715781482 Bentonite Seal 197-194ft.
;:1.�S�r�=•�-�
Canahv P-UeCI I&A fWaliuu No;(PIN)
5b.1.4titudc and Longitude in degmceslminutOdseconds or decitnal degrees, 22.Certification:•-
(if lien fielJ,+arL Iatrlaug ix sirlliei�:m)
35.832589 N -78.604500 _ ��~ - - -- 4/20/2022
Si;tuturcaf Date
6.Is(mi-)the_ti'ell(s}: SlPennanent or ❑Teminirary V. t- x?gt`, f= rr?� '7
'Ul asgnin;;n,r, (ia,r,. .. ,rf,,.i..._9,::`� ;�r ns �,:r:.a co inrcrer!iir rrcranrtncr
IPinY f f,l MCAC Q�C'•�it ;'�-� +i(,rim .o l'.r)�OD 11e?f Constrtl'rlNr Krw.%4w-d.c and dwy it
7.Is thLti a repair to an existing uell: o es or ®hl1T c(pi aj rfiis rPrbrif lists bL e.'i pn%rid,-4 r r bSF•arN rnrner.
IfA,is is a trlxdr,ff mi.kr,oioi ieeii cun;riucrr(ui i+rjurr'ufT:aii and e-kplalii rile n+m.ire of rfle
relvirrrarcfcr 021 remarkssrcii�iT,aron Me.Leuk o0fiis form. 23.Site diagrani or additional well details:
You ilia),use slit Luck of this page to pt&ide add i ion:d Well site details or bell
S.Numl er of wells cottstrueted' 1 Construction details.. You Mai'also attach additional pages if ntcman%
For rnt+ifta k Jef(xWinl(IF OtVl=rt'(rcr supply wells ONLY wirli r!a•mime eonsirlrcriwr,Yon ran
.rr(nnirnnr form. SUBMITTAL iNST T :TiONS.
9.Total well depth betow land 3urfuee, 205 (ff,) 24% For All Welln Sonnets this form witirin 30 days of completion of sielt
For noiirinlr is e;ls iisr nrl doplbs ifdifref nr 4ex4iwnj)1e-3r1 N),a,ul 2P 1i71) eonstmction to Ilie follonir1g:
lu.Static water level h'elow top of casing- (ft.) DIV61iun of Water Resuurces,Informatiou Prucessing Unit,
!f n21;erlr4ri t f:lwrr('usin .foe"+" 1617 Mail Seffice Center,RAleigh,NC 27699-1617
11.Borehote diaincter:14/10 (ia) 24b. For Lai i .11on WON ONLY: In addition to sending lb.,fomi to ilia address in
24aabove. also submit a capv of this fafin withiii 30 days of completin of %wil
M`irellt•(itisinictiou Method: HSA/Air Cousdrnclion to die following:
(i.e.auger,teaary.cable.direct Fasts etc.1
Division of Water Resources,Underground injeelion Control Program;
FOR NVATER SGPPLY WELLS ONLY: .1636 Mail S'ervice Center.Raleigh.NC 27699-1636
13a,Virld(yrpm) Method of test- 14c-For Water Supply&Injection Wells:
Also submit m-- cape of this fufm within 30 daysofcompleliouof
13h.Disinfmion type: Amount: well cowaniction to the county henllh depanm:nt of tire county wherr
constructed.
Forro OW-1 Minh Carolina L\-Var meta of En;irorurciri afU'Nawrfl Rek- [crs-Di%hion Cr Waict rrtm-owoma Rei'ised A auv-Mt 11