GW1-2023-02555_Well Construction - GW1_20230410

i
+�1VELL.CONs,r LJC*rION RECORD \ Farhtscrnal Usc ONLY:
'Phis form can bc'used for single or mompk+veils j-
f 1.Well;CnutrnctorInformation.
tJ:.���17ER'LONfrS .
John Eisenman V14053 tt) Df.S1';Ittfftt(r\
UVICorAnrclortyinw fl. ft.
fL (L
4439
NC iVcl]ContmcrorCcniftcation Nuirber `M.'OUTER CASING trer'rnultltaw-d i cttsi OR LiNER'ilra• Geable)`
FRONI I Dr:►:Lfr,TER Tfr7CtM—S15 i NTAITMAL
SAEDACCO Inc 0 ft. 40 fL 1 211 in. SCH-40 PVC
Valli lt:an•Nalm- It;:INNER CASING OR n'BING;(i;i'vlMirna clo 04 i,
FROSI I To DIAMETER I THICI{.NESS I VATERTAL
?.Wcit Commiction Per'nift R+ ft, uL
liri tall applirrf6lc u-cllpr"'rmirs(i:r..L'nwrhr.Sacs.,trnriarxr.!r}'EYbCIt e5c.j n. fl. [r4
3.Welt Use(.heck well a.sel; M SCREEN
Water5upply Weil: - FROM I to ar"o-1 r4 I stoT8173: t1t1CxNM5 I arATRRrnr.
tJt1gl;tll[utal 17JhhinicipaUPub6ic 40 ft. 60 ft. 21, i .010 SCH-40 PVC
©Geothemul(HeitingfCoolin3 Supply) ©Residential Water Supply(single) ft. � rL
OltidustriaUCmttnicfcial ©Residentia.I Water Supply(slctred) rAcGROIIT:.... ::' ..- • .. :,.
FROM TO, JfATERLIL I E:►TPLACOIENT31EtRODS.LUOUNT
01rti tivv' 0 fL 35 M Portland .Pour
h ltn=�'iratcr Supply 1Ve.IB:
ft. ff.
6dManilaring pRccmzr}• - - -
Injcctlott Well; ft. rL
1�IAquifcrRccharge neirouridnatcrR.ciitcdiation t9i5ANDJC;tL1VIL'CACI{',ifardicyDte!
"�FROSI '10 mxrvur.n7. t?StNr.lCr]\I}:Vl'!47r?ltr7n
13A4140 Storage arri Rccoycry ❑Salinity Snnict 38 R, 60 ft. Sand #2
❑Arptifer Test• 0[1ormnatcrl3rtiri7 p
ri. r1.
O>"?:17.^tin7cntalTvchno[cI�• pSarbsit[rncc(':artrral
2n,DRILLING LOG failach addlliotial sheets If acccssnn•t
E%readtert"(Closed Loop) Mracer 1 fRgb1 110 D�SCittPT1U\fsabr.h;,nrncir,v.Wr+K4�X' pn>irr„�Irl
riGeotheinnal(Fleatine Cooling Retunl) [301her(explaitt ututer•921 Retuar6s) 0 fL 60 ft. Silt/sand/clay
4.Date Well(i)Completed: 2-3-23 Nell IDNMW-10 fL n. '-
+
Sa.Well Locathm: IL ft. _.:.
Speedway ft. ft. 023
facility ftnncrNunx Facility boo j applicablc), ft. ft.
4431 N. Center St., Hickory, NC 28601
Physical Addr•ss.Cit;•:and Zip :21:Rl1►L►HiCS'
Catawba Bentonite seal from 35-381
t'na,uL1. t:,rcel I&IJI ifie;rtiou No.(PIN) -
56.l.iatitud/anilItingittrticindc�tccslminuteslsccondsardcein7aldegtccs: 2i Ccrtiticrtiun:
(lr a¢ll rwid,oue latilwig i;:MEMCLAd)
it W __- - 2/22/2023
siginturz of `:'i:7d�:iJi LRh:!'i :—.— Ualc
6.Is(are)the►vell(s): XlPennanent or OTet moral}' !!r r;:Cnul thin jQ,,,:�r:� �"� ih•rn f S?7 cis t+ice zcl.�7ruzreri iu crconlra,cr
rv*4IMrVCdCO2C Couarp,:rinnSruruJareserndrrar<r
7.Is thL%a repair tar ad cXistin„well- ElYm or IENII c0�,r of 17iis liming!hrc lr.`n j,rerrirlyd fn rhr.sn lJ(gaga,'.
If ibis'Il a repair,fill ruff kaor,vi rvrlf roe ilnrtJ<rri J,rjornarrf.vr mad i elrinhr rlu nrrrare of rAc
rejfair«ruler 021 remarAw seefiara or rm flip.hixf of fins form. 23.Ric diagram or additional,well detailm
You may use the bacl;of this paile tti ptocide addilioiral trell site daails.or well
S.)cumber of►Yells cotTitrttcted 1 cotlstructiou details. You Inav alsto attach.idrlitiotlal pages if access ln•.
For maniple uflecrron or and-11 er sir}ply wells ONLI•tdtfi die samecvfrstrurfivu,yea Cerro
.s:flrrnitarne Ecru,. SUBMITTAL 1NS'I•CTCTfONS
9.Total n'd[depth Mow land surface. 60 (ft.) 24:L Far All Wells: Subirdl this fonn within 3U days of eompletiou of n"rll
For araftiple icells tin all deprhs if fiffi rem lercmple-3re1200'(v1(12 @ lf7o'► eonstniction to jibe follonina:
10.Static water level below top of casing; (l1,) Division of Water Resources,Information Processing Unit,
If imler level Js above eds&q.li fe^+" 1617 Mail Service Center,Raleigh,NC 227699-1617
11.Borehole diameter.8.251' (in.) tab.i nIlijpiDlr Wy lfc OVLY: In addition to senilinb.Ak form to ilia address in
246abo►•e. also submit a copy of this foRu within—to days of completion of hell
12.Well construction Meta:HSA Coustmction to the follonimz:
(i.e.anger,.A ary,cable direct push etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mull Service Center,Raleigh,NC 27699-1636
13;r4 Yield( pin) Atctland of test: 24c.For Water SuQUIX&laicellon Wells:
Also submit one copy of this fern! ►ridiiu 30 days ofcompletion-of
13b.Disinfection type: Amount: well construction to the county health department of tire coarm,where
constructed.
Form GW-1 North Carotin:?Dganment.of Eeviroluucru and Marna)Resources-Division oPlYatcr R i- tr ovx-- R,evised August 1D13