GW1-2022-09171_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD � For ltacrnat Use ON1.v:
This fonn can be used for sinyk or mulliple wells'
1.Wdl Contactor Information:
I4:WATER ZONVC
John Eisenman FROM TO DESCRIPTION
We'll Coniricsor N:tnlc A. A. f
4439
NC Well ComracrorCcniliovionNumbef TS.OUTF.RCASING(for enuhiiascd'Ncns ORL1N R He Ikahk
ROM F TO DtAMETFR. THICKNES5 31ATERIAL
SAEDACCO Inc 0 'tt. 25 tl: 2" tn. SCH-40 PVC
(;aiigruiy t aster 16:1N14ER CASING'OR TUBING eo1bermatclnsed tarp
FROM I TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Pet7nit fl: ft. tt. hl.
List all applicable well p6milr.(Le.t^niaety;Suva.Variance.Irewficit sit.)
in.
3.Well Use(check well use): 17 SCRUN
Water Supply Well: FROM TO DIAMFTER SIR)TSIZE THICKNFICS I MATF.RIAT.
gAgriculturat 25 ff. 40 A. 2^ in. 010 SCH-40 PVC
OGeothennal(Neatin000ling Supply) OResidential Water Supply(single) fl'' ff.
®hldustrial/Commcrcial 011csidcntial Water Suppl'(shared) ig.GFROROG TO d1ATFRLAt. I F.MYLACE MhT\1tn10D fi AMOUNT
Oirti ation 0 rt. 20 ft. Portland Pour
Non-Water Supply Well:
ft. fl.
61vionitoring ORccovery
Injection Wel1: n. if.
OAquifer'Recharge OGrouodoaicrRcmcdiafion 19.SANDH:IWIVEL PACK tit Itteahk
FNOTf. - TO M�TE:RWr, FMFI.A('t;M ENT MFT11O11
OAquiferStorlgc and Recovery OSilinity Harricr 23 !t. 40 A. Sand #2
❑AgnifcrTcst OStorrrm:rtcrDriinagc h ft
❑E%Vcdmcntal Technology ❑Suhsidcncc Control
20;DRH.11,11gG'LOG.(atfach additional stleets'ittleees rti•
❑Geothennal(ClusedLoop) 07'racer FROM TO DFACRIPTIONfmbnhrrdnevi, MkH' nsuc.Hc:
OGeothennal(NeafiggdCooline Return) OOther(ex lain under#21 Reload, See gho s log tt.
4.
rl. it.
4.Date Well(s)Completed: 8-25-22 WellIDIIMW-3R _
'A
5a.Weil Lticaiian: ft, tt. t`y I's.n i if
Malloy Site 0, ft.
FacilNl,r'OwncrNunrc FacrlilylDR{ifapplizablc)
2237 US Hwy 311, Madison, NC, 27025 A. H,
Physical Address,City.and Zip 273 REMARKS
Rockingham Bentonite seal from 20-23ft
Canon Patvcl Willific lion No,(PvN j
5h.lattitudc and Longitude in dcgrecs/minuteslseeonds or decimal(legrres: 22.Certification:
(if sell fscld;one iatflong is quirte MI)
N W ' �rf r 9/7/2022.
Stgnitur:of s > /9 :v :e G— �Date
_
6.Is(are)the well(s): IMPennanent or OTemporan' M signit g ibrs,(er+..�+'L� �+1 �a `�;.1 �j:uner+ueterP i i sett>rrfnnrr
irirlt 1 SA NCAC 02C.'ii-!•:4 'f'"f`ai�i.;::CC A1209 Well Cmrsrroairs Starufnrds and Elrnr rr
7.Is this a repair to an existing well; OYes or ONo a(ry+rnfthiv rrrnn'l htrc In rn p+»rfllld in the arff mtnCr,
if lh(s it a repair,fill rsu knokve well emnintrilan hifornwrlon and explain for mrure of(fir
rr'lmir ttmlrrre2/rrmnrks rrrticm+s�eve the brxk of Ihis fnrne, 23.Site diagram or additional Well details:
You may-use the back of this page to pfovide additional well site details or well
8.Number of wells constructed: 1 colstruction details: You'Inaj'also attach additional panes if ivmessary.
For iwildple tnfecrlon co ese-vi ware•r sttpp7v(Cells ONLP r+Jtle the some construction.yalt Can
.evbniir one form. SUBMITTAL INCTUCTIONS
9.Total well depth t►eFoH'land surface 40 (ft.) 24a. For All Wells: Subn6l this form within 30 days of completion of well
For,prdtil?le trills lest a0 defu a Ifdifferew teirmaple.3@2m,'and 2@ I09) construction to the following:
10.Static water level below top of caring: (ft.) Division of Water Rtesouneew Information Practising Unit,
Ifuvire e lewl is above rasiij,use"4 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter.8.25^ (in,) 24b.j•.cer lnjy I1jtjl gIL ONLI': In addition to sending the fonn to file address in
24a above. also submit a copyof this form within 30 days of completion of well
12.Well construction method: HSA construction to the followings
(i.c.anger.rosary.cable direct pusk ctc.)
Division of*Pater Resources,`Undergreund Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Ser•sice Center Raleigh,NC 276971636
I3a Yield(gpm) Method of test. 74c.For Water Supply&injection Wells:
Also submit one copy of this form within 30 daysofcompletionof
I3b:Disinfection type: Amount: well construction to the cmmty heollh dcpnrimcm of the colmty.whcre
conctnlctcd.
Form OW-1 Nvnh Carolina Dc-parinlcnt of£nrirormxw and Natural Resources-Divsion of%%W6r Re utz Revised August 2013