GW1-2023-02195_Well Construction - GW1_20230306

WELL.CONSTRUCTION-RECO D For iutenlal Use ONLY:.
T1ris form can tv used fir.singled Multiple 15•4:11s
1.Nvell_.Contraitoe•Information:
John Eisenman FROM Ira DFICRIFFIOIr
1t'e1l Caraiarcturl•7rnC., R. it.
4439-A ft;
NC Well Contractor Certification Nurrher 15:OUTER CASING"((o-6iidll=r Irwetlsl'0R LiK f it s'i pcahlc'-
FRONT TO I nrAnlEWIt THICKMESS NIATERLAL
SAEDACCO Inc 0 fl, 6 ft. 1 2" l in: SCH-40 PVC
(an5}5 ur1 Nauu. I6'INNER CASING ORXUBING./i�niluiui il'cEuseJ tai'oj:;:
FROST TO INAMETSR I Tinclu"USS I MATlRIAL
2,Welt Constr•pctirin PCITT it k; (l. ft, •n.
Life irtl npplicnbl.*v,•eN prnrits tr:c.L'nunhC'S!rr!r,k't,riarser,G)rB:df.�}clr.l - - -
R..
3. }�cll:tfsc(chcclC{YPII qS�J,: t7:SCRUN
Water SuliptvWell. FROM I TO I nrAStRTF,R SI,OTSVE I 'IInCK VS5 MATRRIAI,
CiAuirultutal I:1MuniclixtUPublic 6 (t. 1.6 YT: 2" rn, 010 SCH-90 . PVC
Mkotitertiml(liatin�lCooliug Supply)' ®Rcsidential(biter Supply(single) ft, f[ in.
e
®lndustriallConlnlercial ®Residential WatcuSu ly(sltawd) `,tB GROUT ..._
FROM TO. HNIM 4L FAIPLALESIONT 1VIM1011,1 AMOUNT
❑Irri Rlion' 0 tt. 3 rl. . Portland pour
Nqu-Water Supply NVCU: _
f7a1v@pnitgring . ❑Rc+ccn•ciy
Injecticon Welt:
GIAQIIifCrl;CCliBrn�C' �1C[gt110t1R114rRG11Cdl;ltipll. d .-SANWGRAVELP'ACK'(ir_ 7dieslbtel'
'F•ROu Trr NMPI.AMMENT HIT11011
❑A411ifCLS1@r7$C00tl RWGt:4t3' ❑$aliliin'Bam—ct 5 ft. 16 fl, Sand '. #2
❑ArisukrTest ❑swm, 5;1tceDmilb98C f6 fr.
C]tyletim tifal Tccllnotag� I-]Subsidcocc l:atdTal
.�20:'BRILF;BNCI.Oa.'fafiacti iddlfii�ual sheetslf rlcccssn'rti•1
❑Geolkemlul(Ciosed Loop) ❑Tracer FRONT TO t►rsrrttl=Tlur'i'(r,)l3r.hunlncn,H)id'nxlth x:'^ "n vte,tk l
❑&DIIIern al(He;1fin Coolitla_Relunl) ❑Oilier(expiniu under,921 Retua"� 0 it. 16 ft, .Silt/sand%clay
ft. ft
1. )atclYetlQs).Couy►lelcll; 2-9-23 WelllD#PMW=2R -
(r rt.
is weal Lrreation. r1, rc. MAH1
J
Former Planters Chemical Company f4. ((
FacilitylCl vnerI amw Facilht,iW(ifa}rpl):nblc).
610 Commerce.St., Fayetteville, NC,-28305
. PltSsi".a1�Aiidress CI[y_and Zill -,zl REMARKS-
Cumberland Replacement well; bentonite seal from 3-5'
Gonul�• 1 araolld•_IgiCuCaipn Nu:(PiN}
54:1 adtudc anti 1.ringrttrglc in(lcgtr e�lmiiiuteSJseeonds cif dceiln:ll ctcgrccs: y2.CertitlealYala:
(U%1 e11 kid;ow t:unnug is s+Jliei<ra)
11 W 2/24/2023
Date
6.Is(Art.)file%Vdi jr LILY Nx Argni�ig�ihir'jai!':,'.��Yc�i(u
Bich 15A.A10WVC weacwrsrrraiNr graM,errds mid ibli(T
7.Is tkbi a reliaii-fu an e:ii.*u%velle Eyes or []No itgir a}dris rrcd+Ti lfrr In Pn l,rirridrd r?iT.v+�n ll n;rrirr:
,(1r1,rs:lt n rYp+rlr fi17 car 6:rruirvr ri'r(d e�rru�ructlari lirfornu,`rlU•!r,rrirl+�5pfotn rhq rurerre r jnc�
relimr mclrr ll21 rcrnurCS'..5r rllcm nr rsa nc�!rni°k pjrhls jornc' 28;Site diagram or.addltinoat well detailm
You niay use ibe,buck of this pajo[o ptovide additional tc'el1 site details or-%sell.
S.Nuutherofwelts constructed: 1 eonstluction delai(s, You itI 1v;i1sq aftaeti adtliGonaLp i Ls if ticcessaly.
For rimiftptc lideprinn err afar-uarrr supply wef.ls ONLI'vJJi rbu.sewe e{urs(rrrcrivrr,yoan"in
Fre(,niir an jarin.. - SUI3(1![TT'df.INS'1'UCTIONS
9.Total*sell depth bdon land surfaei: 16 (ft.) 244L Far All WV Ilsi Submit this faun tvilhin 30 days of completion of ivell
For kthlple ivdff list i l dccrhs lydtf errnr(cxmr+pk'-8@3R 1',ual.:ups 1M?) consimction.to Ike folloniug:
10.St:atlewater.level helovl'toll ufrasilltlt ( ,) Did€shin of Witter RcSiW rccy,Inferrneatian FrucessinP Unit.,
If 1twee A+i-al Js dLorr edsia;;•am•'t" 1617 hlail.SciTicc Center,R leo,,NC 27699-1617
114 Borehole diameter.8.25" (in.) 2Jb.Rnr Ritlerian Weirs ONLY:'in addition to sending the Fomt'to the address in
242',66ve.also submit a copy of this fund within 10 dayis of cornpletioll of iscll.
12.Well cttustmcdon method:HSA Loustructiall(o the foUoa'ille!
(Le,au�cc rrAa}',cable.dicta gush etc:l
Division of Water tksfiurcts:,'•Uiiderl;I•ound Injection Control Progrant,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Set•cice Center,Raleigh,NC 27699-1636
13:14Yt".eld 24c For Watct°Suaal KIiWc.ctbr/d.Wctic:.
Vim) ATetho�l attest. Also submit of Ci1p} of this farm ilrthin 30'dp.Vsof coniilletion.af .
13b.Disinfection gpet Amount: Nvcl1 cahelnictlun to the county hc;Ilth department or the county n•hou
t:onstnlctrd.
Fonn Gtv-t lronli Corolina Mpxnnicrit.ot Favirounti:rrt and Natural Resources-Divii Ion of Slater tl+1-ar MS kc%iscd August 1#I3