GW1-2022-09187_Well Construction - GW1_20220930

WELL CONSTRUCTION RECORD For hurnil Usc ONLY:
t Thu Ono can be used for single or nncltipk w dis
1.Well Contractor Information:
li.WAT't RZONFS
John Eiseltman FROM ) TO DFCCRtPr1(1N I
Well Colwtacun Nantc
R• fl.
4439
NC%Nell Contractor Certification Nutnbcr 15.OUTER CASING(for atnhhcakd"vvclls)OR L1NER Na Ikahk
FROM To almsirTF.R TRI('KNisS MATIMAL
SAEDACCO Inc f1. ft. I in. l
C01141311)Nauac 16.INNER CASING OR_I SINGIgealhu-mildoced-logp
FROM m TO 0WN1FTER Till(f:NF.SS MATT.RL%L
2.Well Conmytiction Permit 9: 0 ft. 21ffid. -
/j;r till alViirnblr wellpcnr¢itr(i.r.Comer.Same,thriarre,140rvCn r'rr.i _—
fr. IL
3.Well Use(check well usc): t7:S!Itt EN
WaterSuppty Well: i FROM 1 74) DIAMETV11 St.OTSIZr 'twt('KMNS i IMATMI.M.
OAgncuftutal i klonicip:ilrT'itblic 21 ft. 26 fL 2 in. .010 I SCE40 I PVC
0Gcotheml:d(HeatinatiCoolikg Supph•) 011csidential Water Supply(Single) tt. fi. in. 4
iJ IndustriallC:omnrercial 01kcsidcmial\rater Sltpph'(Shared) `8.ROUT 70 >fATERt41. E,11PLt(711FNT\iFT110D A AJIOUNT
❑f fi ation { 15 ft. 0 fL Portland Pour
Non•WYater Supple Well: E ft. rL
®hionitoring ORCCI»ren•
injection Well:
OAgnifcr Recharge G)Gmundwatcr Rcntc(Iiation 19.SANDiGRAVEL PACK IN i ilicabip
FRIIM T¢ �fAYt;Rlal. E1/PLAC'F11ENT MrTnon
OAguifcrStotagc and Rccovcre 135aliniteRuder 26 ft. 1 19 ft. iSand #2
OAguifcr Tcst 05tormw:atcr Miinagc
OExclicrimcntal Tcchnotogy Osuhsidcacc Control
1-20.DIMUNG:tA%(attach additionalskvis if nrcecrm6
❑Geoiftcmtill(Closed loop) OTrtcer I FROM I TO DFSCRIPT ION Iiobr.hrirdpc .a'nhi:t. >t+a wc.cic.l
OGeothential(Heatiinm+Coolies Relum) OOther(explain uniler tf21 Remarks) 0 h. 10 it. Silt/sand/clay
10 It. 26 ft. PiQR
4.pate Well(3)Complekil: a-5-22 Will Ip#MW-208
R. fl.
Sa.WellL/tcation: , �s �,.-
tt. ft. ��
Facibiv,'OKn 'Mu
ni: Facility k iif ampfi ablc+ =-P`3 n z02—
293 NC-740 Badin, NC 28009 Stanly County, , ft. ft. { rii te2d=�� 177'77"nMvil
Plnsi:ad Addrzss.Cite.and Zip 21.REMARKS
bentonite seal from 19-15ft
Cuunh 11artet 10i:n1tftGaliun No WIN'I
5h.l atitudc and Longitude in d(ggnecs/minutc3hecondc or decimal d(gnrc: 22.Ccrtiftcation•
(ifucil ficid,Illy L•itlotV IS%id i:Anri
N H 8/12/2022
6.Is(are)the nell(s): mPermanent or 0Tciniarar.'
Hi•c•"t rrir.�flair her r •.ih••h..:.::,: ,.::.j.a..:.:„� ::r:•rm_rbnrlcvl in rtz•zrrrl<rnrc
WiM)M AICACO C xu Suuuhuelt findtJNn rl
7.&this a re)lair to an eXl(ting well: _VLs or 1M No n�'ry nfrhie rrrftnl ha.tn•rn/!mrgIr•t:to uM•indl Ognrr.
lflleiJ!f iY rrl�rie,ill,lf �/a+N`!1 1}rll('{tllJ7llr,`l�i1i11lif(ir7rMfrt:17 Li7J(1!'.l'filirlrl thin 14i(Mir•elf j1iP
rr1a:it uru/rr ir2l r•murl..v iri-tim or rm the hr..:C o/thi.+form. 23.Site diagram or additional well details:
You may use the Itack of this V•iO tut provide additional well site details or%veil
8.number of wells construcied: 1 Colistruiyion details. You may also attach addllioted wigeS if novessaty.
Fier multil:&igjvtAnt tw,Iltil-N%la'r Arp)Rii wt•11i ONLY talk tiff wMe eaBS►rurth"t,a{:a t'w
.tut mum one form CUBJIUAL INC_TUCT1ONS
1).Total well delith below land surface: 26 [R.) 2aa. For All Wells. Submit this tone within 30 dais of completion of well
Orr muhiple u'fl(r list fludeplltr iJ ihff ervu leuwvtpfe-?G:09'mid 2Gf/f101 construction to the folfowirW:
10.Static water levcl below top of casing: ((I•) Division of Water Resources,Information Processing Unit.
if none,lrt•el ii trht r e rr,:.r t,a se";" 1617 Mail Sm•ice Center,Raleigh.NC 2 7699-t617
11.Borehole diameter.10/6 (in.) 24h.For InWft!n We1tc ONLY: Fit addition to sending the Conn to the,address in
241above. also submil :t cope of"this form wilhin 10 days of completion of well
12.Well construction method: HSA/AIR construction to the following:
rour}.cable.direct posts ctc.{
Division of Water Resoumcii,ifndergr'outld Injection Control Ptrtgranl,
FOR WATER SUTPLY WELLS ONLY: 1636 Mall Service Ginter.Ralclgh,'NC 276994636
13a.Yield(gpm) Mrthnd of test: lac.For Water Sunnh'.-Injection Wells:
Also submit one copy of this futin within :A days of Completion of
13b.Disinfection tipe . -_ w Amnunt: well construction to the county Itchlih de(tanturnt of the comity w9icre
consinicied.
I
Fenn M-1 North Camhua I3cpannient of Ern immix nt aid N:aural Rewurces-Un lion of Watcr Resources Rc%twd August 2t113