GW1-2023-02192_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD For lt¢cnmlUscONLY:
?7lg fbndcan be us d for.sNgleor multiple nc(Is
L`FdI.Coltttarroc Tt(forntaeiou; � '
1:.�1'el"CER:ZON ES:
John Eisenman FROM Ttt DF_iCI RPtION
1401 CoiArrctorN7mo ft. ft,
4439-A
ft. ft.
NC Well ConuaciorCcnifxationNulrbcr `15:OUTER CASING(for''niultl=ciis-ttg ills)OR LINER fffa' Ikablc)
FRONT - TO pr><tIF,TfiR TTtICtiNE�5 �cATERLiI.
SAEDACCO Inc 0 ft, 6 it. 2' ;a sex-4o PVC
(:�atp;uq N�n1c. t6;•INNF.R CASING OR-- MIMS('iroibeim d clams-lab r
F+ROSI I TO I DIAMETL�R T(UCKNESS MATERIAL2.Well Construction Fer•nrit 4: R. ft. •1L
liti aill rpplirlble tsr)l priraits{ix.Crnmtu.Sirm.bilriurlre,frya:661 rrr) ft. ft. .
3.Wdt i3sc(chccl:n'cll asc); 17.SCREEN
Water Suplily MILM: FRONT TO nrAusn:R S1.0TS171:: TrnCXNFti5 I MA"RrAr,
Mgr(cultutal Cllvitinicip!Kf blic 6 rt. 16 fr.. 21, ia• . .010 SCH740 PVC
Mothennal(ficating1cooling Supply) ©Residential XVmcrSup}ily(single) fi. (L in
OludustriaUContotereial ©Residential Water Supply(shared) '6R'GROUT NT ru. srnTtaRCAI GMPt ACENfCYT:SREfiIOD&.LUOUNT
❑lrn nUan 0 ft. 3 ft. Portland pour
Rcttl-W:atcrSultplyWcll: R. tt: .
6�lkfotiitorinG pR�:oti•ci}'
Injection%Ve((: n. ft.
l_lAquifcrRcchargc pCrounrmmuRciuctik4tiou 492SANDI(:IMEL11ACKlir ppiM tev -
VROAI In SLcrrurat, t 51P1 AC.EVa:N7 1M_t•nou
❑AquifceStomge and Recavc,13'. ❑Salinity BarricP 5 ft.: 16 R. sand #2
❑Agnifcr Test• ❑slonnivatcr I}r•,Rina9c
t7E.e11;,rimcntal TMinology. nsubsiducc i.:olfirol
20:DRILLING,WG"(allaeb'addiiio6al iib&ts if itec6sai�•9
Meod t.unu l(Closed Loup] Mrdcer FRONT TU DF.SCRIPTIOx(e)11n.411nlnca x1111tw t lyjx.prell fi/c.<kst
OGevilienual(HeatimVi2oolin2 Return) Ol]tlier(esplaiu mtder.421 RetuaM) 0 iL 16 ft, Silt/sand/clay
ft: rL
4.Date.{Yell(s)Gnnpleted: 2-9-23 well iD#HW-18R
Sa.%Vcll LOcatis)ni
Former Planters Chemical Company ft. R . MAE .j 2023
Facility:'OlrncrNuluc � Facility lI),V�Cappliw;�blc) R, fl.
610 Commerce St., Fayetteville, NC-, 28305 ft. ft. l"I,�;r •'. ,'1'
ra 5.' .;3• is
PltysiridAddress.Cit}•.,andZip '2t:RF:4L11t1{3
Cumberland Replacement well; bentonite seal from 3-5'
Cwluty 114ruel U-1311iftamionNo.(PIN)
Stt,f-arifudc Anil I nn>;itirt[c in dt rccs/IniitutcsJsccnnds or decimal degrtxs: 22.Certitieation:
(ituett field,ow 1a001%is'61dnc.ieW)
N W __ �� _2/24/2023
Sigmwrcofyr.�'_:•�,�. 11"iu,�aCs:.—= Uaic
G.is(are SlPennattent oe OTeinporur}' ;?xE
Up sf g nb,l rhls fu�,6 +4'In ..+ri,..� r n l..e:c/t'tAtsfrirt'red ltr+YY'orlrrltx'
ti'irh 15:4 NGRC r72C•'<%=�^-l:•;t�iris u.:C-,n:pD it�'rl cott�(�;r�rrol�srorxrRr�is<rr�rr rl�rr�r
7.is tftis.a repaii-fn an ciistin,t hell: 99V�w or ONO i<ryirgfrhis ictorrl h7is't r,^n�it:rirlyd rnlhr.croJ1 mrncr,
!f rbls:fY n n�lxllr,jib u1r kr;nitdt waif r;rumrcticri Htf�rrra:rloa mill��.l�laln rin�rl,rrare of r/�c '
rinair rardrr 021 remarks scrrian or tm tbt:bru•.0 of tfUs fora 23:Site,diagram or additional,%veil detliits:
You tray use Uie;back of this page ro pfovide addi.ional well site details or(sell
S.ItRttitberof itcllc constntcred: 1 couslitictiorl details. You illayitlso atldeliridditiouaf agcs if Itccessary.
For walrlple frrfeefi n orison-ranter n pp)y melds ONLY o1rh rlk'snmr emrs(rik6o'ir,you ecw
a iruiirn�ir form. SUBMITTAL iNSTUCTIONS
9.Total Well klich below laud surface: 16 '2f t•.Fur All Wells: S-nin ut this fonn within 3u days-of completion of li-ell
FornNpleWelklist ail dtprhs!(di i'roulcsanry,le-.f�?f1A'arul.:nslf4)') r0nsinectionto111efoilon ug-.
M.Static Water I&CI I,elpw top of caritttH A.) DivMun of Water Resnurces,Infornintipn Rtneessing Unit,
1/mver level Is abuts c'os(eg,iuc""+" 1617 Afail.Seivice a enter,Kaleigl,y.ETC 2 7 699-16 17
11,Borehole diameten 8.25 (in.) 24b.For iniecti0n Wells ONLY: In addition to sending.tita f0mi to ilia address in
-14dabove. als6 submit a-xopy of this fortis within 10 days'of completion of tttlt
12:Well constmetion Method:HSA c0115iniction to the f0110%vin0::
(i.e. u;ec rcaan'.cable:direct posts e(c.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:' 1636 Mail,Set•s'ice Center,Raleigh.NC 27699.163E
13a,Yield(>Iim) Alctltod of test: 24G For Water Supply&[Weetlon Wells:
Also submit one copy' of this:farm'within 30.days of coniilletion of
13h.Disinl'cction t3 e: Amount: wdl cohMniction to the county hcallh dcpatinmit of the county whore
constructed.
i
Fa nu GW-I No"It Cofoltra D panmcN of EnvRoluwut and Natural Resource®-Division of Water Etr-away, Ittvised August 2013