GW1-2022-06740_Well Construction - GW1_20220628

WELL CONSTRUCTION RECORD FarirtcntalUsc.ONLY:
This form can tb laed for cingle ar rnultipk n'cils
i
1.Well Contractor Information:
W.H`ATER ZOMS
John Eisenman FROM I TO I DF:S('RtP1'It/.N
1Wc11 Cor mow Mum A. ft.
4439A ft. ft.
NC Rrell ContriclorCertificaliunA`iurber 1.15.OUTER CASING(for molikasYd wells!OR LINER fit a Ik bkl
FROM I TO K-#%METFM I THICKNESS MATT-HIAL
SAEDACCO Inc 0 fit 92 fL 6 ia. SCH 40 PVC
coot/mi-N;2VIC 16,INNER CASING OR TUBING i'eothermrl dosed-lute I
FROM I TO I DL►\IFTER I THICKNESS I MATERLiL
2.Well Construction Permit R: N/A 0 (L 105 ft, 2 ijL SCH 40 PVC
fisr aid ar,LyaHrabfe%V-H pr.'tmits(i.C.Crnuitt•.S1L1e.Iarduree.I'�'EiiJC.1 nc;1'
3.Wc1IX'-.l(check well usc): I7_Sf'REEN
Water Supply%%14.l- F-nosr. t To DIANIFTFlt %1.0T5I7I: THICUNKS5 I MATERIAL
C1:1g1itulnlra[ bMunicipaU'Public i 105 fL 115 ft,. 2 iu• .010 SCH 40 ( PVC
oGeothemlal(1H&1dng,`Coolin_,Supply) ORa-cidential Wiper Suppb-(sin0e) rt' P ft• in,
®IndusWil- anmlcrcial ❑Residential Water Supph'(shred) 18.GROUT
FROM TO NmTERU L- I EUPL►MTENT M IOD&AMOUNT
❑irii�Ition 98 ft, 3 fL AquaGuard Tremmie
Nou-Water SupjrlcMell:
❑Rcco�•cq• 3 ft.. 0 It, Portland (pour
6ahlpniit)rinG
Injection Well:
p' gi ifer Real irge 06roundwowr Rcliwdiation I9.6aNbi(;KA�CL PACK fir applicable)
F•ROAt-" Tj) II ATFR6►6 FAIPIA(X►ENT MI-rn(in
❑AtjoMrSto-mgc Mid Recovery ❑saliniri`13'imcr 115 ft. 103 ft. SAND #2
❑Alluifci Tcst ❑$Ioimnatcr.Dr,,iiti
❑Experimental Technology 0S11b5idCnCC Comral
20.DRILLING LOG fattach sdllitionnl sheers if necessary)
❑Gebiliennal(Clukd Loop) 13Triuef. FRONT m DEiSCRIMON(mlor.liartlno,.wil'nick tr n m c.AGI
❑GothenuA(Heating+CoolineMuni). ❑Other(explain under 921Retoa&-,) 0 ft. 48 fL Saprolite / PWR
48 IL. 115 rL Bedrock
4.DafeNell(s)Completed, 4-15-22 W1.,ll iD#MW-38C
rt. rL
5a:well uscatioa: rL rL
Corning Incorporated N/A ft. ft:
Facililylb wmrN- nee facility iDT(ifapplicable!, R rt.
3900 Electronics Drive Raleigh, NC
Pinsi.iil Addicss City..aDd Zip 21_REMMK:
Wake County 1715781482 bentonite seal 103-98ft.
0-Moll P.lri:el IJ,:Mirtcaliuu Na..(PiN)
5h:l::ititudeand l.anfiifide in tlelnti`esJminu[c�i. buds dr decimal'ilcgreck. 21 Certificatiou:-
(irti�tin fxld,Mtn`I:w9uug is sirllicknl}
35.832589 -78.604500 4/
20/2022
_ -fir` L4/ e
6.Is(are)the_well(.s): oPennanent or ❑Temi►orati'
tlr aignir,�rir5x luf,n. rF, r,a1 !i x ..:.i r.�::1:umrnrered itr-rcxorntmiCr
n'i1r1 1 SA NCAC OX•'s+�'1:i:La+�.z.1.O200 Weil tbaislrat6-i Sroolrirds quid rhTs a
7.is this a repair to an 6istingwell: ❑Y" or ®No_ rq y ofrhia reer,rrdhac heeri pnniderl r,1�re;ii`d!rnen,�r.
IfrLds.lr a,,,q%1r,f H rwi tttrntvi wd1 c•vrumrcdw'j itrforcuu;wi cind a plah rhe;narl,re of rhr
rrpcirrirnfrrd'�f.rernurks.irrtiara or rxt die bail gfthis fnruL 23.Site diAgrarn or additiuoul well detliiCe: ,
Yau ma}'use the back of this O'ge to provide adilitionad well site details,or well
8.Number of wells constructed: 1 cvusiroction details. You Ilia'alsaaltach adds ional pigeS if necessal'r'.
Fqr tnliUlr-dc wA'-%'Thvi or racgi-uevee nipgv iedis,ONLY'nirh die-wive cTTrrsrructiwr,-!:t:laCain
axpinlr,me foris: s11 uTTAL[VSTITC.TiONS
9.Total vw.].depth beloir land surfnci-, 115 (ft,) 24m For All Wells: .Submit this foml within 36 6ys of rornpleliod of well
Rur twiMple ieeiff lin fell deprhs if diffty i!fe.y4wiJ1(t•-JrZ,ta t1tT ca/g1.2@ 141,) consliuctioa to 111C follo"Ing:
Ill.Static water level below kip of rasing: (ty,) Division of Water Resources,Information Prucessink Unit,
if want/hovel is vbuee Cusi}a!;,rase'"+" 1617 Mail Service Center,Ralei„h,NC 27699-1617
11.Borehole diameter.12/6 (in.) 24b.For JoICCtion Walt/ONLY: In addition Ia sending 111F:fomr to the address in
24a aibo►a. Ao subinit a copy of this fortil within ,Q days of Completion of well
12.Well enustruction method: HSA/Air constmctiotl to the folloliine,
fi.c-auk r.r»4an•.cable.direct push,crc.I
Division of Water Resources;Underground injection Control Program,FOR WATER SUPPLY WELLS ONLY: 1636 Niail Scrviee Censer.Raleigh,NC 276!r1-1636
13 r dd(g►m) Nfetllnd of test! 24e-For Witter Supply&ID jcctian Welts:
Also submit one cops' of this farm within ati da}•s of con)pletion of
13b.Disinfcetion t}pC: Amount well constnrction to the counly�ticalth depnment of tite cmtnnv where
caei5mrcmd-
Foml GeV-t Nonh Camliiw[X-pnnxia of Ens iroanicia Laud Nauard Regiunes-Divi;ion of WaierREnotrcc5 Revised.l guA-)