GW1--03347_Well Construction - GW1_20230512

WELL CONSTRUCTION RECORD ForirtarnalUscONLI':
This faun can In usad far single or nitdtipk teens
1.Neil Contractor Lnfornlation:
Yd:.WATLR ZONES-
John Eisenman FROM TO OMCHIPT1ON
Well Cor=ctor Name
4439 ft. fL
NC Well ContrictorCcniftcatiotiNunitcr .15.;OUTER`CAStNG dlrjilatli=eE kde icttsl`OR LiNFR(if a'it16
FROM TO PEA-SIFTERTinCENESS MATERIAL.
SAEDACCO Inc 0 ft. 58 fL 6" in. I SCH-40 PVC
('ante;uty Nmttc Id:'INNER CASING OR,l'UHINGi(Ceaittei'mid cluscJ-btu`)' -
FROM TO DtAStETER TIIICANR55 MATERLIU.
2,Wdl Construction PGlmlit#: NIA 0 ft, 65 ft, 2^ in. SCH-40 PVC
1JFr irLr 0J�7hi rJlde v.cllpenuilr(i.e..Cnuart•..9jov,Cor(urce.Iry,'ert7Cab rr,:J ft. ft. ill.
3.Welt Use(chtxlaticll use): 17 SCREEN
Water Supply Welk FROM TO DrAdrE.TER 9LOT5173: TniCltNt,S I MATERbtI.
❑Agricultural OlvlunicipatWublic 65 ft. 75 ft. 2" in, .010 SCH-40 PVC
❑Gcodlemtal(IicatinWC0011119 Supply) Mesidenrial RraterSupply(singly) ft. M 1
❑hidustriaUConnnctcial ORcsidcntialAVitcrSuppb•(sl><ilr(i) =18 GROUT .=
FROM To AMTERFAL EXPLACEMENTAIM101)CAMOUNT
❑irriagation 0 fL 3 fL Portland Pour
Non-Water Supply Well:
3 fL 57 ft. Aqua Guard Tremie
MkiloniOring 1111cm-cry
injection Well: rL fL
❑Agltifcr RCCltargC Qtirotttxlwatcr Rcnicdiatioq 319YSANDIf:RAYEL•PACK(if Avid i6brO
-
FROM TO NI&TF:RIAL I ESIPIJI(:FMENT urnion
QAgnifCr Storahc alyd RccnvCn' QSalinin'H;trricr 61 ft. 75 fl, Sand' #2
❑AquifcrTo ❑S(onnwatcrDraina:.,c ft. ft.
❑E..Vcrinicnial Tcchnolol,v ❑Subsidmcc Cordrol
2ri DRiLLi\C`LOG;(iillach 8dditi,iiialsficetstf necresartil
❑Geothemutl(Closed Loop) ❑Tracer 1 FRONT TO OF-MUPTION(tobrJmrdoca,.r,iyntel,tt fe. rR n uvc.cic.t
❑Geodtertal(Heating+Cooliug Return} ❑t]thcr(4 plain mRier t)?!Reutarks) 0 fL 60 fL clay/sand
60 f, 75 f, PWR
4.Date Well(s)Completed: 3-7-23 Well IDsIMW-40B fL fL
54.Nell LIIC;It(Iln: ft. ft. + .,`t,�•�,.,'�Y:
Corning Glass Works N/A FL fL
FacilitpUivncrNan+c FaciN)-ID#(if apphzanblc) --
ft,
3900 Electronics Drive, Raleigh, NC, 27604 fL ft. r�?r^G"y-M'�•`
Physical Address-Cim rind Zip 31-REM1tARM,` v
Wake NSA Bentonite seal 57-61'
Cuuoq farce]ldcntiricrtioti No.(PIN)
5b,lattitude ant)Lou};itttllC bt ifGgncsfnninutCsiscComis pr dCGimal flGl i'G15: 22.Certification:
(Irkldl field,ottV Intlong iti stlRickni}
35.830758 N -78.603564 �>.• �. '�_-' 3/8/2023
Sigatturcaf _�r:'a'•�-': 7;('u„!•�:;.`- -- �— _ - Da1c
6.Is(are)the twell(s)r EPertna lent or ❑Tennporat}` � ^v r�su f��� :c-7
lli s:g)th, riir lint, ilr!i?3 1 t,:rrar cxnrinrrrrd in recewrlcnce
ni'll Cr,nsrrurr irnt Sromdards and TI.Va of
7.Is this a mpairto all existing well: O V&--s or K'N11 e4?pl{y(IIAi fP1'f+,t11,(L�'Irr!!pnil'1r11'd1 rA llr Ut•11 nmiu•r.
if tl:(s 1F o f<•Jxrir,Ir1 ra',r Crrntrri rcrlf rc,rurnrrr(c,fi 1tr/oruurdfnt anf7 erpfahl rube nvrr+re•rf rhr
reprir under 021 rernardx.wriian or,:m the hark of/his form. 23.Site diagram or additional wetl details:
You tuay use 4te back of this page to provide additional well site details or w•el l
S.number of wells constructed: 1 eons(tu ctimt details. You mat`alsi)attach addifioual pages if necessary.
For to iNple l,*vrlon nr am-it'ctrer suplili•n•rtls ONLY iorh rube sirme corrstrlrcliulr,}'e=n aatu
.1avntrrmu forin. SUBMITTAL iNSTLTCTIONS
9.Total rwelt depth betuw land surface, 75 (TI,) 24a. Par All Wells- Subudt this fume.twithin 30 days of compic6on of well
For maMplu irafls;isr fell rkprl,'s ifdiL i f<nr fernr,,,p(:•-tr.i77 and 2@ fw'1 construction M the Follolvin;:
III.Static water level below full of casing;: 25.85 (ft.) DIvi\inn of Water Resources,Information Poucessin.Unit.
lfttxu,v Ind is al,rn'r cnstii;r ase"+" 1617 Mail Bewley Center,Raleigh,Y('27G9')-1617
11.Borehole diameter.12"/6" (in.) 24b.fnr Inihilon WeIW ONLY: lit addition to sending the form to the address in
24a above. also submit a copy of this form lwitbin 30 days of conipletiou of it-ell
12.Well construction method:HSA/DMD construction to the followfiw:
(i.e.auger.rulary,cable direct push c(c.l
Division of Water Resources,Underground injection Control Pro;rani,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,YC 2 7699-1636
134L Vield(gpm) Method of test.. 24c.For Water Suppy'&injection Wells:
Also submit one copy of this fonti within 30 daysofconipleliot of
13h.DisinfLe inn type: Amount: well construction to the couluy itcatth depanmetu of lily county w herc
_— constructed.
Fonn GC\r-I Nonh Carolina Uepanarcni of Ent trowuctu and varnral Resources-Divsior,of Waicr Resourem ileviscd August_H 1