GW1--03351_Well Construction - GW1_20230512

WELL CONSTRUCTION RECORD For hitcrani Uso ONLY:
This form can be uwd far single or muilipk wells
1.Welt Contractor information:
'MMIERZONFS.. t.
John Eisenman FROM 1t1 I DF_ICRIPrn)I
5!'e11 Coiuraaar Natnc
kill. ft.
4439
NC Well Contractor CeniftcationNimint tS;'O<)TELZC SfNG`foi uauhiri'seiiweFlsl`ORLtNFR(tt i fkabkl
FROM m Dla�t1 TFR 7tt]rti�VI TVIMRUL
SAEDACCO Inc 0 fL 253 (L 6n in. SCH-80 PVC
Cougrmy Name 26 INNER CMI'NG'OR>TLIBING i6ike clozad'lu
FROM TO D!tMETER 711ICKNESS H.i7EruAL
2.Well Construction Pei-wit R: N/A 0 ft. 256 ft. 2 n SCH-40 PVC
1�ar«R c}.yrlirnhle ur11 p,nrui+s fir.Corrntc•.Shav,114d rrcr.!r)-'ac6e b rtr.1 ft, ft. - irt.
3.Well Use(ch"Imcll use):
17 541tt EN,:
Water Supply Well: FROM i 7o I DvvimxF.st T SIATSt7%: I 7111000SS I MATMIAI,
LIAgkultural Lihlunicipal/Pitblic 256 R. 266 ft. 12- JnL 1 .010 SCH-40 I PVC
Meothelnrel(HeatinglCooting Supply) CiResidemtial Water Supply(single) (I. fL
Cl lndusiriat(Cununcfcial OResidential INWer Supply(slxtird) �A GROUT _.
FROM TO MATERIAL ES[Pr.ACEh1LNT]nElniOn&AMOUNT
❑irrination 0 fL 3 (L Portland pour
Non-Water Supply Well:
3 ft. 250 ft. Aqua Guard Tremie
Mhlonitoring ❑Recover•
Injection Well: ft. fL
❑AquifcrRccharge I-r3roundiSalcrRcnicdiatioll F OArtlif]iGlt�O:EL'+CACILI^ItTF,RtLt�) F:MPI%CrS16'\TFiFTn(1n
❑Aquifer Stor,igc and Recovery 05alinily Bernier 254 ft, 266 ft. Sand #2
❑Aquifer Tcst ❑Slom%vAter Driinigc
fL ft.
❑Experimcniml Tcchnolnr• ❑$ubsidem c Control
'2n;'+DRIGL1i\G'LOG(at(ach sddltr "' "'omen°sheets if neccsrsn•f
❑Geothennul(ClusedLoup) ❑Tricrr FROM TO DESCRIPTION(color.banlnca,xti'nAo-roe,% 1isife.Ne1
❑Geodtemnal(Heating+Cooling Return) ❑Gdter(explain under#21 Renwrts) 0 (L 25 ft. clay/sand
25 ft. 50 fL PWR
4.Date Welt(s)Canipleled: 3-29-23 WellID#MK-43E 50 fL 266 (L Rock
Sa.Well[arcation: fL ft.
Corning Glass Works N/A fL rL �✓�r.; °"'' "-"-
Facility-KhvnerName Fac(iil}-IM(ifapplic.'ible) ft. (t. MAY 1 uMT
3900 Electronics Drive, Raleigh, NC, 27604 ft. rL
Pli}sieal Addmm City.and Zip ' 'Jn
=2LRCMARKS-;, 1n c;,,r,; ;.:.
Wake N/A Bentonite seal 250-254e
(:%wary Pane]]rmntiLe;dion No.(PIN)
Ski,Latitude:Ind Longitude in dcgr•ccsiroinutt:.sfscconds or dt'Cimal dcgives: 22.Cerlification-
(if a ell rwld,one lat•lmrA I%sidlickrd)
35.830758 N -78.603564 ��• = _- 4-12-23
Sigtntnrc of: •'r:'�'��':9; v dt.?i;. _- - -=...- Dale.
6.is(are)Ure w'ell(s)r SlPenuanent or ❑Tenquorat}
Hr srgntiiR Pkir(b+rr ,'• .4Pref�•. �.;n••+., .,i+:e:�i cx�crrnrrrexl iir rrcre.rrPann•
n'irii 1 S;1,VC..4C ozc.';�-�':�•�-r::lfC:ir�'�:Pt:,tt:fJV?11i'i1 C'nnsPrP+t'nilq Sto+ufnrPis ame!rlktr er
7.isth6a repair toanrmisingwell- 0Vc-s Or NNU eryirojdiisrevonihnsly,rni»nri,IP•rllorh+:nNnu+Irr.
1f rMis is n rels�dr,fli rn9r krrnnlr ur!!c•cr+u7+u'i 7krn Nrfureus3i+n auxl r,17+inln rlar�+I�+r,Pre rf die
repair render 021 re markv srcile.-a or an the besk of Phis jnrm. 23.Site diagram or additional well details:
You may use Uie bacl:of this page to provide additional%Veil site details or%veil
S.Number of wells coustrucied: 1 eonsiructiorl delaits. You ina}'also attach additional pages if necessary.
For,nulriple lrrjee-rlon at oven-uzrter supla r wells ONIA'}rlrh the samrconsrrurdim.yva rein
xaagjjdr one jemn. SI BMI'171'AL fNSTUCTIONS
9.Total well depth below land surface: 266 (ft.) 24a. Ear All Wells: Subndt tltis form within 30 days of completion of well
Fur,uailrilife welk liar efl,trpOn it dit)e•rent(arampk-3@21-V'and 2@ 199) construction to lite following-.
iII.Static water level below tap Of easing: 40.15 (ft.) Division Of Water Resources,Information Processing Unit,
If Irmo.level is allove cres?11;"am"t^ 1617 Mail Service'.Center,Rack h,NC 27699-1617
it.Borehole diameter.12 n/6 n (in.) 24b. nr I i nr WeIty ONLY: In addition to sending Me foml to the address in
2 to abate.also submit a capy of this fonn within 30 days of completion of well
12,Well e11ustructiou method:HSA/AIR constructior to the followine:
(i.e.auger.rolar}',cabin dint push c(c.) I
Division of Water Remurees.Uuder'ground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen'icelCenler.Raleigh,NC 27699.1636
13;1.Yield(glim) hletliod of test: 24c.For Water Supply&Igicetion Wells:
Also subunit one copy of this fofnl within 3o days of completion of
13h.Dirinfcetiun hpe:. Amnunt %veil constriction to the count. henith department of the county where
constructed.
i
Fenn G%1-I Nanh C3GAIIIt L\-P2nr1!Cur Of En%HOILI 11 and Natural Resources-Division of 1Voic,r il(-Kotrcr— Revised AuglM 2al:i