GW1--04200_Well Construction - GW1_20230706

WELL CONSTRUCTION RECORD For imntalUse NIN:
This(but-loan be 115a far single of multiple.1t'Ctts
1.Welk Contractor Information:
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John Eisenman i tftwm f 1D ! nrtsctttorma I
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l4'4at Cntstiny,+ar Nangft, ft, i
ft. fl
9439
NC Well Cnntnctor Certification Nastier t.tS.OfiT&( CA.SL Gi€rirrnuitiodotrtocticl:OR INERtif'W Dcablett
i FROM I TO • DIAMETER TRIWNICESS MATERIAL i
SAEDACCO Inc ii. I ft. In.
Voavoy Nom i ff.0(8.81CC".r tPiG;Oft 1G tNCd indlie-taalif>frstil l4ti,J?D ._ ...:,
f imoi1 TO al,L1t€`TCt{ TIIIC'CiNI %1AT1 Ritl I
2.Well Construction Permit'4: I 0 ;ft, 5 ft. 2 in- SCB-40 PVC u K Epp
fairarldnejnli,ofaf.•u•rtPyrn.^.Vr(r.e.t'rn_ulf•.,.St:!r.tiarr£arcs+.i'}'A'�Gll !rri. "'
1 R !t III,
3.Writ li5c(cheek well use): - v:.. ,
Water Supply Well: I FROM I TO I nt%'WTER I SLOT DUX 11111 Ii iIN.0 I NIATE llAl,
1 5 ft. l0 ft, 12" in, . .010 SCH-40 1 PVC 1
CI tgficllitttril Olvltudair tlfPoblic r Ia
0Geotitountil tilooting,Coolin;;Supply'( rLtResitlentittl Water Supply.(single) ft it , y
Clittdnstrialicoumtcrcial URes;idential WaterSipply (shared)
r Font, l 1a IIATC.aFa4 i ES1PLACEAIEVT411. 'I4li5&,1.SH1L1T1
❑!rrtontan 0 ft. i 3 ft. Portland Pour i
ifort-Water Supply Welk ft. f 33
•
' g f f I
IttjecainnWell: • • �, �..w.: .� �. ,.....
i'JAquifer Recharge Otikoinidit.iler Itt:ntedi:ttian "v•SANti'tcdytst�t:L:l*l.Ctetifit i1tiesaitel • 1
FRf4ht t la, NIATrttfMG FMMPf_Attatrs tlf,`rttan
°Aquifer Stomp and Recovery f.�Salinity Harrier 4 ft. 110 ft. I Sand .#2
°AgttiferTest CDStannwatcrDrainage ft. I ft r-
L]Fxlscntucatal Technology p5u41Nckaisc Comm! •.1t:111111tLING LOG=1att.tcttallifit70n.tI fiteFt ifttL'vtsaril
r It eothettn:il(Closed Loop) CITracer 1 1:nnst TO DRICRIPTi0\twt;r.tranlncoi.Au litrtli Ow.;,rph;err.itt I
OGi:atileMP.at i11eptLiitg1COobuI Return) OOltitf toVstaiit under#2 t Reittat ) 0 ft. 10 ft. Silt/sand/clay
•
10 ft. ft. rock
4.Date Welt(s)Completed: 6-14-23 Well IDt#'f4W-1 tt ft. s n • !
Sa Well lunation: j if, ' ftr
t--- 03
2
Residential Property i ft. fl JUL� � 0 6 1
Fc, iliWKIIIT.1 OM radii')Rix{if Pplizahlc5 _.
. —lfaiva.i'atta. ...9-r.'7 ri i,? --YDZI-0-•- .,,----.h. --•'a
89 Rattlesnake Branch Rd., Canton, NC, 28716 1 [t. ft. Gt�3�ti3 a
Pinsicat,Addr ss.city.aril Zip I .gl.RtItIAttKs _ ..�..-. • w
Haywood _ , € bentonite seal 3-4ft 1
Cann!, 1*tree)ltlra"trl'IX.IUD Na MP:ft
51%Latitude and I.omdtttite in ticgil.'exfmintfteslsc,;ands or decimal dL trcest ly.t`et lificatitin:
Of wen Ikid,OM I:W101.t iti Si flCt;n I
N 6/15/2023
L.r..
5igroutie of ii fat.9,,;i'i.l{i'::,,:tr:<i; =_. - bear
G.Es fare)the /cll(s): $NLrnrnent Cr 7retfNtatti .f'''' , _..la# ."fJ ;e t ' Jr,+r,r4:',...---
ID
svihr gar Po fir` . rr,Ift•Ir, a n
1„e,.f£z+:ontcrttl:tt r warstra3ty
OA 1*.I•WAC U?C,'s -t---,••-6,3.:A..-f;.'t..020 Writ(`raitiu tt rfea statkidetit.art{that A
7.Is this a repair to an misting well: Vies or l0 No eoin.;ithh rcrrnt3 bay l c,,frrt;ridit'd to riv..n'N rrrcar.'r.
obi.,35 0 te{rr,fiti r .;lar.19-117.1 P.Vii Cr':40ftlIo lino tliii-oheihti area,,e.re4wrt rh'R0Uttf,3.1 r(ir
rr'IL?I!wart P:1 n'!inack.5..i.Ilion or 0,1 fhr bark at ads prim 23.Site+lla rant or additional well details:
You only use t11a bock of this(qv to provide additional well.site details or well
3.number of shells constructed: 1. ti. construction details, You may Mist.+ttftacft additional pages of ne .ss iny.
For.warn f.:Riee'ribli sae rttav-tn.rrt'r 0.0ph tvetfs ONLY omit Mr trtk t.pm coo
srrcnut one fi rrt. SURNI IT TA*,IC+rSTIIC"PIONS
9.Total%%eil depth beton laud surftl e; 3.0 (ft,1 24a. fur AU Wells: Submit this form withitt e daps of completion of well
Pre.'ti,Mht+rfe r..tilq,4ib ufiflopr}atf,fe.C,'r'rprlf tnknpi+£^-lim?(,rr)tram'a'frktt constntellan to the Following.
tt).Static water level belay cup of casing: M.) Division of Water Resource,Information Processing,Lull.
Ovals,:
tetr. ,„i.c+r,•.usfn .trs£•" 1617 Mail Service Center.Raleigh.NC 276I9-16L7
11.Borehole diameter.:8.25" tin.) 2-0h.For fulatut VI I ONC let In addition to 5til1ditu:the fain]to tt =a+tdress in
2sa above. also submit a com or this faint within 30 days of completion of well
12,Well ent.Stf•Itetiau n'iQtliu t BSA c0ns1WWCtion to the following.
d I.C.anger.rotary.cable.di cct past.etc-1
Division of Water Heyatirecs.Underground Injection Control W rogfant.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27499-1636
2 k,.For Wafer Supple&Inleellitn Welts:
teach lrtrld(gout - Method of rest: _,_ _ -
Also submit owe copy Of this'afana withinit) days of-completion of
13b.Disinfection type:... ...... ... . Amount: .
c tctctl. the , e tltlt department of the counts wham.
well construction to county 1
con
Firrni OW-I Nonli Carobiut E:'Attutu^in of Eel;itnrrotsfrt Old Natural ltexosees- Dtcaipr of Water a.r_tttrcr 1-10 sett August:9)13