GW1--04532_Well Construction - GW1_20230713

WELL CONSTRUCTION [tECOitl) vx,� FijaNcnalUsct)N4Y:.
This•form cam bo•U ed frir.single Or ntultipk wells•
I.WeIt.Coutritctor inforutation: `�
\ 1.I.ATER ZONES..
John Eisenman t'tO0 ' 10 oyso'Mss o
t�'cli Coirxracior Name ft: ft.
ft. • • it.
4439 -
NC Well Con1ractorCertification Nunllcr "tS.IOUTER CASING(GO iaultt-caved dellsl'ORLiNER:firt ppIicabfcl. -.
PROfil TO • DIAMETER THICKNESS - MATERIAL
•SAEDACCO Inc ft. IL In
Contp;un-Naine. ,IG."1NNER CASING ORr1'il®1NG,ti;,errskerit at duud-lolly)'° .-
FROU i TO DW:METER TIIiCKNESS MATERLAL
2.Wctl Construction Permit-#: WM0501555 0 R. 10 It. 2 in, sal-40 PVC
Lireallelp,JicablcNeatpear.itsfi:c.County.Stuts,l'iriance.lty'a7i&irIetr:.) f{. ft, in
3.Well Use(e,heck.w'cll tise)d
I7:SC;REEN .• . . .
Water Well: EfltEI I' 10 UTAM.TER cI0TSIPZ TIIICKNI_xS 1 MATRRIAI. t
CJrl�:ulttlral DbitinicipaliPitblic 10 II. 20 ft. 2 in. .010 SCH-90 PVC
EIGeoth:mlal(HeatingICoolitlg'Supply') ©Residential•WaterSupply(single) ,II •
' ft.: in.
•
DTndustrialiConmtcrcial °Residential Water.Supply(shared) •t8;t;ROUT _ . ... . .: ... .. .
FnOh1 Tt?. MATERIAL i EMPLACEMENT AIErr1OD&..C110UNT
❑lrripatian . . . 0 ft. 7 . ft. Portland Pour
N to-Water Supply Nell: R. R.
ldhfonitoring- . fRccovery _ ,
• Injection Well: h. ft. !
°Aquifer Recharge ElOround'rwrRentediation • -19:SANINGIt VELIACK(1r:atrplicible ' . -- . , -
"vs0;t1 10 . NI.tTFRrAI. - NSIPLACENlENT fiii:rtirin •
17 Ai)tlifcr Storage arbi Recover', ❑Salinity Barriee. 9 • R. 20 IL . Sand • #2
❑Aquifer Test- ❑Stotiiiwatee Drainage
ft, ft.
❑Eylcdmcntnl Tccllncltortt GlSnhsidcrtcc.(rordml 211.DRILLING'LOG(attach additional streets 1f ncet sart't ' . . - -
. t7Cr.'olltennal(Closed Loop) ' ' ❑Tr-ecer FROM -- TO DESCRIPTION(tVtcr.hardneti,tn4'rck OK.:s+dnwe,de.t •
❑Geotheitual(IleatinioCoolingReturn) ❑Other(explain wader.#2I Rettturls) 0 .it.. 20 ' ft, silt/sand/clay .
tr. It.
1.DatoWcll(s)comlpleted: 6-27-23 Vt{l.iD1/Mla-14
54.Well Li,eatinn: .ft. tt, 1 'L ..,,,‘..e 3....t v 4—
Former Catsburg Country Store .ft. ft. - j1 i 2023.
Fa,i]it}'rV3ntxrNalao Facility 117k(ifappli ablcY. ft. ft,
1110 Old Oxford Rd.,.Durham, NC, 27704
Ply scat Addiess,City..and Zip :2 c RlML%RhS . . . .
Durham bentonite seal from 7-9'
County Parcel ld•_rditioailouNo,(PIN) .
51t,Latitude anidLongitude in dcgiecslminutcsisccnndsor dechilaldegreei: 22,Certifcatioa:
•
Of Mel'had,oao latfloug is.mairei<rd)
h W yy —r-_-. -- 6/27/2023
• Sigmtwtu 1: ••••0...i. :.:;: —=- r' ... : .—Dale
6.is(are)the tvell(s); ZIPetnnattent. or ❑Tetnportr} `,r'vr !: ,fa 1. �.�fa
lir si ni ••'kir for,6• ari.r,..:.:::E ..5.rt n::... at runytnicied In rrceon&rricr
ti'ith I5a NGtC 02C x-•: -'1,:i •t'n4 vai. O200 We fl Cr uct t rrnn crnrvlcrads'and:1. r rr
7.is this a rgfiair tit ati cf:istinl;tvelii ❑Ve_v .o'r :1 NIB 4.6.11r fdike'rM•urrl Ws/steal(?»rid d c?7hc%I V/if/mien
if 0;4107 repel'.fill tear kr?.rrual rrrlf c+r;tu'ulrctioo lrtfgrrtr.7doll ilia,_tii'tabi(be,tl,taut'of rue
repair under 02l rern,,rLs scztl m area ncu ticrc of Mir form 23:Site diagram or.additiouat well details.:
Yon may use the back of this page to provide additional well site details:or Well
S.Mnulierof;veils coustructed: 1may,'details. Youmay,'also attactiadditional pages if mcessan.
For retdrlltrc-irtieer)on or mewl-''seer supply n'ils ONLY n'!rh rAe.sarrtrsoasITIMIO r,yoo,tint
srbnrirnnc f,an.•a. EJIDMiTTAI.iNSTUCTIONS'
9.Total Well depth Moil-laud serfrice. 20 (ft.) 24a.•Fur All Wells: Submit this farm within 30 days of completion of welt •
For nrulriplcii'Urlestial 1eprhsiftittN•rt r:(i•.ratiipre-•,r€s•2110'ard2@1OO') constnictionta the follotsing:
Ill.Static water level Imlow top of easing; 11 (fit.) Division of Water Rcr(Itroces,Information Processing Unit,
if wait'?Ire,/is itbove.cask:,;tit'"+" 1017 Mai[Service Center,Raleigh,NC 27699-1617
ilk 13archritc diameter:6" 'OIL) ,2111:Fir wow Weill ONLY: in"addition ro•sendingllle form to the address in
24a above, also submit a.copy of this fount within +(1'days'of completion of Well
12.Well construction method:Air - . cottstmctioil todhe following:'
(i.e.auger,rotary.cable.direct gush.eidl •
Dtvisl(nt of Water Resources,Underground rejection Control Proglaul,
FOR WATER SUPPLY WELLS ONLY .1636 Mull Service Center,Raleigh,NC 27699-1636
I3a,b icld'(grfm) hlccflad of rest: 2-;c_For Water Supply&(njiefton.«'ells:
Also submit one"copy of this form Within'�0'daysofcotnpletion.of
13h.Disinfection type: Amount: well canstniction to the calmly health depngment of the county wheie
constructed.
Faun OW-1 NonitCarulina[kpanmcltt.of£oyirflrinrm and Natural Resources-Division of Wale;Rnotrct Revised release 1013