GW1-2022-08793_Well Construction - GW1_20220909

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WELL CONSTRUCTION RECORD 11� For hvental Use ONLY:
This form can be owd fm si"ek or multiple+yells
1.Well Contractor information: \
td.WATEIt ZONfS
John Eisetaman FROM TO pFJCRI 1 i.If
%V01cordnootNantc
f►. fly
4439A
13.OtlTFR CA&SIhC tfirnh1r_ 1 h" 'ORLN EcNC Well Contractor CcAifccation Nrmtbct FROM TO n Ik Bie
11AWRIAL
0 ft. 5 ft. 2" in. SCH-40 PVC
SAEDACCO Inc
((tStpally(\ante -16.WNER CA:3ING-OR`1't)Bi IP `eothermat rluud;; r
i'ROM TO DL4NtETER THICKNESS NLe7T.R1AL
2.Well Constivetion Permit a*: it. ft. hi
list till ripplirahle u-tll prnnits a.r.C'onnn:Stale,1 arinrrce,lr�'El'OCn ev.) fl. ft. In.
3.Well Ilse(ehmit+Yell use):
Water Supply Ily Well: FROM TO DIAMETE6 .sims1v. TItICKSI\5 NIATKI1141.
I1 5 f1. 15 fl. 2" in, O10 SCH-40 PVC
iJAgdcultural ONIunicipal/Public
oGeothem+al(Hc1 ing/Cooling Supply) 011csidential Water Supply(single) U. ft. in,
DIndustriat(Conmicrcial 011csidential Witcr Supply-(slured) 1F514ANDIGRAVELIPACK
r TO NIATFRtAl Edip=cTMENT.%irnlotl&ANIOttST
Olrri ation 3 f1. Portland Pour
Non-Water Supply Well: ft.
5dhtonitoring ❑itecovrr?injection Nell: n.
0AquifcrRcchargc pC.1roun&-nicrRenicdimion (if llicable
FROM TO MAYt;Rt�t, 1 MPI.ACI IIE\T M!"1 flnll
❑Aquifer Stor:lgc aid Rcco+ety ❑Salinity Barrier 4 f1. 15 ft. Sand #2
0AquiferTcst ❑StonmvitcrMtin.7gc ft. ft.
0E\7lcdo cntal Technology OSubsidcrtcc Control 120.'DRH.UNG LOG1stiach addhionatshretsift►cccssar%.
OG•othentud(Closed Loop) ❑Tracer FROM TO DFSCR1Pn0�(tubr.hprNncy�>tdl'ntcL h' ri 3rC.Mca
DGeotlremlal(Reatiol tooling Return) 00ther(explain under k21 RemarW 0 ft. 15 ft. silt/sand/clay
it. n.
a.Date WOO(%)Completed: 8-11-22 Well m#MW-1
-,� 14...• , 5
52.Well Locathm: ft. ft. SEP
James Locklear's Grocery ft. tt.
Facili yA0,tvncr Nana Facility ION(if applWhIC)
UnR
11163 Rennert Rd., Shannon, NC, 28386 ft. A.
Plnsict0 Address.City.sand Zip 2 L:REMARKS' "
Bentonite seal from 3-4'
Robeson
C_amyt+• Pat el hkldifoc:niot%No.(PIN)
56.l:ittitude and I rongitudc in de.grecstminuteslscermdc or decimal degrees: 22.Certification:
(if+rel)fold,ow latilpq is stdlieot:ul)
8/12/2022
K W
Srgrutor,of/� 1 `i `� r~
6.1s(are)thewell(s): &Permanent or IJTCmIMlran' M r�morr�,•rh fin.. /. I•C;1y�,1 ss .,•r;.Jise'*,1 consttnrted in avoMrmce
1414 154 NCAC 02C Well Crnrom tfnn Srnn4trr<s tout sent a
7.Is this a repair to as existing well: OYoi (or ISiNo rfyl of dais rermt'Ilutt-horn pn-mideli raj the rill ax•nrr.
f/W5 is a rejoMir,fill int R»onm rill erutsmrrtPnmbrfimturtl(m rind rrpinin rha tumor"f(fie
relnrir tioderg2l mitarkt-serlim nr fm die 8rx•F of rltix form. Yo3.Site diagram tsthe b additional well Details:
1'b»may use tl>;back of this page to provide additional well site derails or well
8.Number of wells constructed: 1 colutluction details: You may also atlach additional pages if necessary.
For.ndtidple ieleetlon w nrAt-fearer Strpjviv ivells OjVI 'wirlt the someconstruetion,vox etm SUBMITTAL INS1IUCTIONS
suhmir One form.
9.Total well depth below land surface: 15 (ft.) 24a. For All Weus: Sublitil this fowl within 30 days of completion of well
For.narblpfe rc.gls Rsr all deluhf lfinf1'rretu!evompfe•3@209'(1tut 2t MYY) eonstmction to fate following:
10.Static water level below top of casin . (ft.) Division of Water Re+oumes,Information Processing Unit.
1 t: 1617 Mail Ser+•ice C•entcr,Raleigh.NC 27699-1617
lf.svihu level U ofove coding.use
11.Borehole diameter-8.25" (in) 24b.Frrr lii,(Mi i1D WSjLi ONLY: In addition to sending the foml to lite address io
24a above. also submit a copy of this foun withiii 10 days of completion of well
12.Well construction method: HSA eonstmction to lite following:
(i.e.aug,r.romp.cable dime gash etc.) Division of Water Resources,Undergmund Injection Control Program.
FOR WATER SGPPLI'WELLS ONLY: 1636 Mail Sen'ive Center.Raleigh,yXC 276994636
24c.For Water Supply&injecOin Wells:
13a.Vicid(gpm) Method of test Also submit one copy of this fare) within 10 days of completion of
well construction to the county Health dcpnnmcru of the cmmty when:
13U.Disinfection npc:---_ _ _ Amount
constructed.
Fonn C,t\'•t Nona Carolina Ugxtnntetn of Environn ent and Nautral Resources-Di+eion of Waterite•sotrtes Revised August VoI3