GW1-2022-09182_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD For litenr:il Use ONLV:
Thi5 foimcaa it used thi single or nuillipk ttclls
1.Well Contractor Information:
14.'WATER ZONfS '
John Eisenman FROM it) or-julupl m
Well Corriracun Name
4439 R. ft.
NC%Vell Contractor Cenifcation Number .IS.OUTER'CASIIVG tfot.mullksktrl,,WcOsl OR I,iNFR if a Ikabk
FROM TO MAMETF.R Tir/C1:�E55 MATERt.V.
SAEDACCO Inc h. ft. in.
tonpcun Name 16.INNER CASING OR:Y11Bf141 -:4 talAcrroattlnxMiiu
FRO*1 70 PLAMRT'R THiMN.S I MAT FIRL
2.Weil Constivetinn Permit#: 0 tt. 31 tt. 2 in. Sch-40 PVC
I-ecrrill alydis.aM•Nrllpenult,fix.Cmolt.Shr.e.Voriierre,1jer cit rig.) --mom--�-
h. fl. is
3.Well lice(check well use): t7 S!it[Ln
Water SupplyW'ell. I FROM I 'to I nIAMFUR SIAMMY): s/,ATF.RIAL
ClAgricultural 13Municipal4lublic 31 ft. 41 ti. 2 in. .03.0 Sch-40 PVC
I;IGeothemt l I Heat inf;:Cooling Supply) 011csidential Water Supply(single) ff. � It. in. i
iDindustrial/CUn1t1 ucial iJResideallml Water Slipph•tsbared) IFRA r GROUT. 70 I ?fATF.RIAL E\1PIAlT.11E\T MFTItIOn ll.l�l01�\i t
Dirfirnation 17 h. 0 ft. Portland Pour
Non-Warcr Supply'Well:
®Monitoring DRcco%-cry
inject on Well:
QAquifcrRccharge 06roondivitcr11cutcdiation t4:SAND.K:ItAVE4'PACiCfi► dicilbte
►ROM 70 MAU#MAt• R�IPI 1rY'bE\T M►T110n
DAgnifcr Stortgc andRltmrn' DSalinif<-Barrier 41 f�. 20 ft. Sand' #2
❑Aquifcr Tcst OStormwaicr Miinagc
DExp;rimcmal Tcchnology ❑Suhsidcncc Control
21):ORMLING LOG faitack additianal:sbeets if nccessen-
OGeolhemml(Closed Loop) D'I'mcer FROsr Tn InFSCR1VT1O�fiobr.h�rdMa.vlil„K4r. .:n.�c.i
DQviltennal(11eatil(elCooline Rcium) DOther(explain under 9.11 Remarks) 0 (1. 10 ft. Silt/sand/clay
10 ft. 41 ft. PiQR
4.Date.Well(sl Comple(cd: 5-5-22 Well ID#MN-204
it.
Sa.Will[Aviation: H. h. Y. ,•r x. a ;iL_,
rt. rt. S F P I Q2?
Faciliirtl%crrr N:inic riclin 109(if amh ablcl
293 NC-740 Badin, NC 25009 Stanly County. , H. p
Cya�lJr
Plnsi al Addrem,Cit..and Zip 21.REMARKS
bentonite seal from 20-'17ft
Counn. I'MMf Idrrltifi Alms No,oPIN'1
Sh.latitude and Lnngitudc in dcarecs/minuic51ecnndc or decimal dcgrve-: 22.Certification:
(ifuelt field,ow lot long ii 3idlic►cull
i
N H• f 8/12/2022
Sirnalurz of r\ Dale
6.Is(are)the weti(s): •mPennanent or DTemporarr
ifr aanil•,;rhrr fen..: ... ih••._,:`e:.:-.r..,;.0•,�.;i•;r::i rer!sburlyd m rcre7alrriirc
With)_frl Alc'iC OTC : .02019 Well 6mtliai ti'.:u Srnn+Mt A in d ihn,41
7.Lc this a repair to an existing well: DW.% or Il:Nll CC{p nl rJiir rf*'fine hc,+In rt!1»»rvd�d!n lh.'tern ulrnr t'.
if 18i't leer re)ullr'fli feu enemy WWI rtsnbLii WIM Mfl PA.ti111R11 tnul rt'J+luln 114'J111(aft'Uf d1l' '.
rrrmiramfer 921 rrmurkn'srrfi a or fa(lie hra'k ufthir forrli, 23.Site diagram or additional wdl details:
)'Oil ntay use d►e back of this page to provide additional well site details or well
S.Number of►yetis constructed: 1 collstmction details. You m:ry als0iittt:ich additions d µages if rl tiessay.
1{tI'!NIJhiJ�.+[ii"�irY-Ild�li i�r r/I:Vt•N'13:f'r.J1iJ11h15 i-e•lli 0;%'1J'u tfi die some evirstrart m.Y!at ve'u: .
=61-tit t?nr forr./. Cl_ BM13' AL iNSTDCTIONS
9.Total well depth below land sttrfacc 41 (R.1 24a. For All Well%: Subinil this fonn within 30 days of completion of ►►ell
For rnshiple N'1•rit lilt fill depths i1 dif rrr,ll tcmnrple•.•r4?�_09'01141 20/00') eonsinlGlon to the follominl;:
10.Static water level below top of casing: (M) Division of Water Rmourcex,Infilrmstion Processing Unit.
if Nrurt ler[t ii.d,q?vr i ww)p rtm-•' 1617 Alail Service Center,Raleigh,NC 276"-1617
11.Borehole diameter..10/6 (in.) 24b.For init�►llon Wc1_k ONI,.V::L in:addition to sending the form to the addrc%,s in
24a above. also submit a copy of',this forty within ?0 days of completion of well
12.Well constniction method: RSA/AIR constmction to lite following:
(i.e.anger.ro4ara.cable.direct posh etc.)
Division of Water Rcsourccs,=URdero„roond injection Control Program,
FOR WATER SUPPLY WELLS ON'LV: 1636 Mail Ser'icr Center.Raleigh.XC 276"-163(i
13a.1'idd(gli m) Meihod of test: 14c.For Water Supply A Injection Wclls:
Also submit one col»° of this fonii wilhio 30 days of Completion of
13b.Disinfatiun qpc: ,r ,_ Amount well construction to the county health dcparlairtu of the county when:
consinived
Foun OW-1 Nonh Caiolum Dcpanna:ut of Ent nuutiew and Natural Rcuunces-Dk iiion of Water RI ovcts R %iwd AigumA N)13