GW1--04966_Well Construction - GW1_20230807

WELL CONSTRUCTION RECORD ` For lrtcrna!Use ONLY:.
This Conn sari be used fai.single or multiple twits• Cram\
I.Wclt.Contraetor Information: \ ✓I
:t.r:.WATER ZONES
John Eisenman _ FROM TO IwSCRIPTION
!:'all Cormutior Nano ft. re..
4439 ft. fi:
•
•NC Well ContmctorCcnificetionNu,rbez 't5'OUTER CASiNG(toy iudlrt=ca%rt0 icetlsl OR LtNER"flfan-tieabki _
FROM TO DIAMETER THICKNESS MATERIAL
SAEDACCO It.•� ft. to
Comp a).Name. 16 INNE1 CASING OR-TfrBIN(o 0;eititwimat etaiedaon , ' :. _ •
FROM TO DRMETER THICKNESS MATERIAL
2.Well Construction Permit it • 0 ft. 10 ft. 2 'ire- SCH-40 PVC
Lilt nll applicable well peimi n(Lc.County.Stale,Variance.flea*or.)
ft.- ft. in. . .
3.Welt Use(checl:will use): :t7_SCREEN
Water Supple'Wen: FROSI� 1 Tiro otaue:TER. Sr.OTSr7.E TIICCtcNrss I NIATF.Rr M1I,
°Agricultural D1vttlnicipali ubhc 10 It. 30 II. 2 in, 010 SCH-40 PVC
1]Geatliemtal(Heating/Cooling-Supply) :Residential WiraterStipply(single) ft. I IL in,
©Residentiall\'atee.Supply(sl tmd) 1&GROUT
FROM TO. MATERIAL I CMPLACESiOHT!HEIHODSASIOUN.T'
o Irrigation' . . 0 ft.. 5 ft. Portland Pour
Non-Water Supply Well: - • tt. fl.
Ilhlonitaring ERccovcty •
infection Well: ft. . ft. -
°Aquifer Recliargc OGtontidw;ticr Rcnicdiation •ts2 SAN DIGRAVE L'PACK rr iippiktitth t . -
"FROM TO • ' MATERIAL. EA LAcEm6:VT H LTriOI
. El Agnifcr:Stortgc awl Recover}'. 17Salini y Darner 8 R. 30 R. sand #2
•
CI Arinnfer Test ❑Storm r to[hainage .
(i.. It.
CDEsperimcnlal Taihnology DSuhsidcncc Caaire
'-20.DRILLING,LOG(attach Iddltionitl sheets if neeesuirvl
DGeotkental(Closed Loop) oTrecer FROM . TO • DESCRIwnvNtobit.riardnav,w4'mc4htx:P-finSin.(Ka
OGotbeintat(HeatinelCoollua Return) oOfher(explain under#21 Remarks) 0 ft. 30 ft, Silt/sapn�d-/clay
ft. ft. i Z Li L. •k?�$r:5...
• 4:Date Well(s)Completed! 7-10-23 Wdl i ffMW-1 R. ft •
f1
So.Well Location: .ft. ft. AUG 0 7 2023
Granny's Bait & Tackle ft.- ft, 1fi€viivAi D.1 Pr-- c„yo„w;r.g Ur.&
Facility,OwnerNuruc FacilityIliN(ifappliobte). fl. ft. tr':�:or `a
6830 NC Highway 8, Lexington, NC, 27292 ft. . . ft..
• Physical•r<ddtcss,City.and Zip ' '3t.REMARKS'
Davidson • 'bentonite seal from 5-8ft
County Parcel Itkiiiiftcidoii No,(PIN)
. 51i.Littihtdeand'F.ongitude in degrccs/minutcs/stconds tar decimal dcgreei: .22.CcttrifcaHDn:
(it uoII Odd,one Iatlouy is•srdflcr_iit)
N W ---"—— -- - -----' 7/11/2023
Signature of q?:^l:a,•'••n-C.I ldiec.1;..` Date
6.Ls(:ire)the ii'ell(s): SlPenuanent or DTemporary r zty icf: ,rr:;`f -r...z� ,
H,signing;kit faiir. •y ii.in:._ n. ..fir+i us r.:e.. cemalryckti in;accordance
riith(51A'CIC03C.'1.,.e;h.-Y. -.:TC..5'C.0200ItidCmrsnta.wnSrnndardsgirle1a7e tlf
• 7.is this a repair to au csistutt nell:' DVAN or OONo toprof dais irconi has bra'pr icb d r doe//oiuicr,
If thfs:It s rrperdr,fill iWir ks oily:Well crrn roar/au lnfcnisass)oa and e.t(daln the a,srnre of the
iip,:ir fader 021 rernarks sec iian or ism the his&of this farm.. 23:Site diagram or additional.:well details: .
YOiu niay_use the back of this page to provide additional well site details:or il•ell
8.Number of Welts constructed: 1 . . • coiisltuctirhi details, Yeti:nay als6 attach additional pages if nccess rtv.
For ntaftlpk htfeciltin for non-never sapp/p rerfti ONLY mills the saerecorrsrraction,On can
.ibaiitone fore.:. SUBMF1TAL iNS1IJCTIONS
9..Totiii milt depth below Hand surface 30 (ff.), •21a. liar AU Wells: Submit this farm ivittun 30 days of completion of welt
For iu thlptc u-thrust 01 depths lit: :Tenor teratnpit•-3e200.awn@ WO construction to Ike Cottoning:
10;Static water level below top of easing: (f,)' L)ivisitiu of Water ROpueceti,Informsttion Processing Unit,
lf waive/rvel Ls above tssfor,sue"+" 1617 Mail.Ser vice Center,Raleigh,NC•27699-[G L7
II.I)areholc diameter:8,25" (in_) 24h:For Ipjsxt)gri Weill ONLY: in addition to-sending the fort to the address in
24Ia'abov'e. also submit a.copy Of this faith within 30'days sof completion of Well
12.'Well construction method:HSA construction tottie following:•
(i.c.aukcc totally.cable,direct lush etc.) -
. . - Dlv'islan of Water Resources,Undergro utd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a VLdd'( fm) Method of test: tie.For Water Supply&Infection.Wells:
Also submit one copy of this Cann icithitt 30.day'sofconipletiotiof
fib.Disinfection type Amount: well cbirstnictian to the county health depinime t of the county where
constructed. • I i
' I ,
Fomi OW-t Noah Carolina Department of Euv'iroiuucrn and Natural Resources-Division of 1Vaier Reotrcut Revised August 2013