GW1-2023-02202_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD FerfmcnialUscON1_X
- lils rarrn can tx used for 3 ftfc or multiple wills-
1.11'c1l:Cautntctor Information: I '
'14.,A i►TERZONFS .-
John Eisenman MOM 'to DPSCRIPTION
►`'c)I Corwreclor MA PW fit. fit. I i
4439-A
fl. fit
NC Well CaMmcfarCcnift©tionNuwhcr 15.OUTER CA5iNGWdr arhfll-&%c'd nc[10 OR LiNL'R'fli:a"`llca6k)
FROM To DGMMETCR'- TfDCi:M MATERiAL
SAEDACCO Inc 0 ft. 6 ft. 2" in. SCH-40 PVC
(onrr;ui]Ivany -M INNER.CASING OR'Tii®1NG(iwfieridal ctused-Iran' .
FROM I To DFAIMETIER I UHCK,*qESs I MATERIAL
2:Wcil ConAtr pctirin rcl2nit R. ft, iIL
ljrt all npplirahLr xeil pramits(Le.Cotouy.:Sta:e,Variarxe,by dC4 eli-,r fit. ft. in
3,N4'cR fist(cheer.well rise): [7:SCRLr'CN
%laterSupplt\rielh FROM TO I WAMVTUR I sr.orst:% I TIIICKNEYs MATERIAL
t'Jelgricultttrat fJlvltiriicip��UPublic 6 ft, 16 fir. 2" Im 010 SCH740 PVC
mx6thef]nal(Hcating(coolin Supply) ®Res'idri]tial Water 5uppl},(single) fit. fL. firs
❑Industrial/ContutcrciA ®Residential Water Supply(shared) 18;GROUT-_
FROM To. MATERML EMPLACEMENT AIMOD A AMOUNT
❑irri ration 0 tt. 3 ft. Portland pour
Non-Water Supply`Vella
�1Vloniiorinl; Mcm-cry
fit. fl:
Injection Well: «. fit.
❑AquiferRCChakge 0 onntln5tm116nctliation 19:SANDIGP. ILVELPACI{'aif' iilieaDfe)''
' 'FRAM TO �LITFttrAr. R�IPIACENr;V1'\ItTW011 - "
❑AgniCcr-Swinge and Recosery ❑SAinity Rude( 5 R.: 16 fit. sand #2
0At)nifcrTest. ❑s oM*TM`3tcrprrinngc fL fit.
13Expctfmcntal Tcqhnarolgyp5tiiisidencc:t=aiNml
20lORIGQ:ING'l:0ar"datlucd:additiunat SticNs if irccc'ssnrcl
❑Geodiemritl tClused Loup) ❑Tracer P740M To idriSrRFpT101 haWr.hnrdnc.M.x,Rh+,cr.h x.grain wactCl
kotlrenitsl(Hea[inilCooltim RetutW ❑Odier(esplaiu under#21 Retuarfss) o It. 16 tt silt/sand/clay
❑
([. YL
4.Date WeH(s).Qitnplctcd: 2-9-23 Weji ID#PMW-10
ft. ft.
U Wcl Locatarn:
Former Planters Chemical Company fit.- ft,'
Fao l " nn''
ility,'l,,•ncr ��A1-AR—
Namc Faciliq II)k(iEapplicablc). {t li z-02
fit. fit.
610 Commerce St., Fayetteville, NC,'28305 fit. fl. ,. s'. c ;';, , _ ,r� (j"u
Pin siealAddresLCity-andZip :ZI:ItEnL►RhS ""
Cumberland Bentonite seal from 3-5'
Nice]Irl--nliHGalou No,(PIN)
Littitttcle anil 1 ongititila in do rtcslmiuutcslst erinds rii dccimul ticgi ccs: 22,Cc tit'cation:
(if M all l-xld,Pik I:iL7i+ug iK grd(ickrd)
W ice' ._- ��r_"-- 2/24/2023
Siemuire of ..Pi . �]i i:.�r:;-f— - Date
,.
f,.iS(arc)lhc=well(N): 817?crtuanette or nTemporar}' llp d,'gniii�+Fir fulir�r :; E i(� i� ,rfi3.N.;4 wws. yj rorxii rcrcd In ax ordancr
ri'+ilr!fill NCAC OaC.'x rti t-l: 7(+ice v'C A:OfI tti'i!Coirstrtn rion Srarxfani.T<oid rlurr a
7.Cc this a rciiair61 an eristin-`yell: ElVes rir ®NII 4'4pY nj'rhlT/PfAlrllrhSInen pm1'iilf(l fPij'+'SH`lf rnrri,'r.
If rNSIf a relMlr,fill rx+r 6794-4 h(jpraxailon an!f ctpfrahi the rrain/e of the
rrprirra.-fcr oV rcmar.Cs wahm or iar the bark-bf this•form. 21 Site diagram or additional wrtl details:
You may use ilie•back of this jmge iai ptovide'addilional well site diatails.or tseR
8.Nintiberof►yells coonstrUted: 1 coust]iction details..You inas:tLai ssary.
For jttm?d e hejectiim cram-u'raer sitpply wefts ONLY rWrh Me sarree earratrurllv+r,co:r rrrn
st.+Fm tine form. SUBAi1TTAL MMICTiONS
9:Totil ieelI depth iicloir'land surface- 16 (ft.) 24! For All Wells: Sithitdl this faint tvilhin 30 days of cornplelion of n'elt
For irrrihiple ii•uUs list all depoi ifdtf i'rou iermnple-3@21A9•aiu1.201A1 P) eonstroction to file foiloning:
10.Static water level helew tap.of
cif casing- (ft.) UivEsiun of Water Rer'aurces,Inforniatiuu Processing Unit,
A'r lfwwor ul is irhoru casing;I'm ' 1611 mail eryicc Center,Raleigh,NC 27699-1617
11.Borehole diameter.8.25" (ia) 24h.Fak Urjolilit µ th ONLY: In addition to sending tire,form to il►e address in
24dabove.also submit I copy of this forth within 10 days-of completion of nrll.
12,"Well construction Method:HSA consiructioo to the following.
(Le.uiigcc raaaR',cable:direct push cr4:l ,
1livisiou of Water Riscurceff,Ilnde.rgraund frijcction Control.Program,
FOR WATER SUPPLY WELLS ONLY 1636 Muth Service t tin'ler,Raleigh,NC 2*9-16Ki
11a,'Y)eltl'(gjim) \Ictlrod of test• 24c_For Watch Suplily&Injection.Welts:
Also submit one"copy of this;form Within 30.dpys of cotuOletion.of
13b.Disinfection t`"pe: Amount:" wdl constniclion to the county health departinent"or the county Mich:
canstnlctcd. I '
Fann GW-1 ;latursl Resources-Whi lon of Water ttn_oucm kylsed August 2011
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