GW1-2022-09170_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD For Imcnal Use ONLY:
This fonucnn be used for sinnk or mullipk sells
1.Well G)ntractor Information: 4
Ai.�VATLtR ZONES ii `
John Eisenman FROM TO DESCRIPTION
l\yeti Cancriclor Naas:
A. A.
4439
NCWcIIComiacaorCcnifcearionTtwi�bcr `I5.OUTER CASING fora►ulti=crsxiiaells`UItLINT.R(if a` Iks
FROM TO DIAMETER- THICKNESS IAIERIAI,
SAEDACCO Inc 0 ft. 75 ft, 2" in. SCH-40 PVC
(:oliip:my 91m a 16 INNER CASING OR TUBING ',eolberrufl b d tnop
FROM TO_ DUVNIFTER THICKSC MATERIAL
2.Well Construction Permit#: rt. m. hL
list till rriyWrahrc writpmnits fi-r.rotutty.Suar. arinuce,IjWlic 1 em.i fl. A. �• �
3.Well Use(check well use): !7 SC.RLCN
Water Supply Wlll: FROM I TO ntAstmR .$LIITswx I TnicKN ss I \IATFRIAL
l7Agricultu►al IJMunicipallfltblic 75 tt. 85 ft. 2" i?• 010 , SCH-40 PVC
OGeothemnal(Hciting/Cooling Supply) OResidcntial Witcr Supph (single) p. ft.
®hrdustriaUConancrcial ORcsidential%Pater Supph•(shared) iF8 GROIJT TO MATERIAL t ENrP1AC7ME\T Mi f11QU A AMOI\T
Oirti ation 0 ft. 70 ft• Portland tremie
Non-Water Supple Well:
A. R.
®Monitoring ORccovcty
injection Well:
OAquiferRcchirge OGrouidnatcrRenlcdiation 19.SAND/GRAVELPAC.Kfir rllicnMe
FROM In _ NATFRI:�t. N.MPLA4"1`+�tENTMt"rrt011
OAquifcrStor igc and Recovery ❑SilinitV Him,cf 73 ff. 85 ft. Sand #2
OAgiiifcrTcst OStorrrrmatcrDrlinaggc ft ft
0ks7scrimcntal Tcchnolegy OSuhsidcucc Cordrul
20 DRA,I,ING'IiOG:attach additio"el sitters ifncccistirr
❑Geothemwl(Closed Loop) OTracet ,FROM TO DVSCRtPt1ONt0lor,har4tioi owntekky1w. tiAbe.om
OGeothemral(HeatinaiCooline Return) 001her(cx lain under 421 Remarks) see gho s log ff.
h. h.
4.Date Well(s)Completed: 8-25-22 Well 1D#MW-19D
5a.Well IAIC1141 n: ft. tt.
Malloy Site ft. ft.
Facilfiye'OscrcrName FacIthy11V(if applWbrc) ft. ft.
:^
2237 US Hwy 311, Madison, NC, 27025 ft. ft.
Plissical Addmss.City.iind Zip 21795ARt{S'
Rockingham Bentonite seal from 70,-73ft
(;auieiy 1'attel lit.nliftculon No,(PIN)
Sh.l:ittitudc aoit I.ongitudc in dcgim4minutestseconds nr decimal degrees: 22.Certification.-
(if%tell field,one tatnoq it mdlitkml)
N W _ 9/7/2022 a_
Sigmium o!e; h x he Datc
i
6.Is(are)thewell(s): WPennanent or OTemporan' .:,.,1 a.•o t•.a..t.Onrllii[ferl tit M'i'prfltinre
n•frh l t,(NCAC AdC.'y..:'.'-?-f%�`7:his.:;:di':(12�n'ei!C;tnryrrrei-rinr Srmuiarrls calif dui p
7.is this a repair ft)an existing well: OVs-N Or RiNo rnpp of this rrr'nrtl hrs�l+rra 1tm r1drA m the esil mm��r,
IfINS A tepnle,fill rrrrknokm x'ell cmunuwfoa hifornwthrnmul expfnln rite nartme of rite
relrtiv underP'21 rrmnrksxer7iou tie on Me bru•k of flab form. 23.Site diagram or additional well details:
Yol nrr)'.use tie back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction Bela ts. You inny also attach additional pages if necessary.
For rnitrrlple 1n(rerion a prat mnrer rirppk teAlh 01VI.1'with dw some ronsrrucrior,you Can
submit tint firm. SUBMITTAL 1NS7'[iCTIONS
9.Total well depth below land surface. 85 (ft.) 24a. For All Wells:. Submit this form'within 30 days of completion of Well
For nathtpk wells tier 2c-1p1'i'i construction to the follmsing!
10.Static water level below tap of casing: (ft.) Division of Water Resounes,Information Processing Unit,
if st air+level isah(we rasing•nee"+" 1617 Mail Service;Center.Raleigh.NC.276994617
11.Borehole diameter.6" (in,) 24b.ar tlrieclion Wc)1s ONLY:'In addition to sending the fonn to the addrew in
24a above, also submit a copy of this fonin within 3A days of completion of well
12.'Well construction method: Air construction to the following;
(i.e.anger.rasa.cable.dicer push ctc.)
Division of Water Rcsourccs,linderp'onnd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 276994636
13a,Yidd(Irpm) Method of test 24c.For Water Supply&injeclon Wells:
Also submit one copy of this form within 30 dlys of completion of
13b.DixinfiYKiun type: v ,..._ _ Amount: _ well consintction to the county�hcahh dcpanmcni of the eounh•when:
constroctcd.
Form GW-1 Nonh Carolina Deprinicia of Em-irotuncrn atd Natural Resources-Division of Waict Resotrom Rcs•iscd August?+)l3
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