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GW1--05164_Well Construction - GW1_20230818
• WELL CONSTRUCTION RECORD `'�p�1� For Internal tTscONLY: • This Corm can be mod tin single Of nnillipk wells \-)\ 1.Well Contractor Information: \ John Eisenman FR(151 TO DESCRIPTION - Well Contractor Nam rt. rt. 4439 ft. ' i ft. ' • •NC WdI Costnictor Coniftcation Number AS:OUTER CASING tbrrnutli-c•Ascil'iiclls)ORLINER4if an'Ileabte) FROM TO - DIAMETER TIItcicass MATERIAL' SAEDACCO h. rt. in • Coinpany N rni 16.INNER CASING ORTI1BING'tgeoikermal closed-loop)-' • FROM TO - DIAMETER- 'HOCK-MSS MATERIAL 2.Well Consttifetion Permit# . 0 'ft. 20 •' ft, 2 'in. SCH-40 • PVC Liu all applicable wellpcnr is(hi%County,Sigh!,trarkorre,Tryixtioq•rrr..) ft, ft. tn. 3.Well Usc(cheek well use): 17'SCREEN SVaterSuliply Well: — -- - - FROM TO • DtAMF.TER SLOT SIZE TRtCKNt s MATERIAL • DAgm~irlturdl tl Mttnicipal/PtibliC 20 It. 30' ft, 2 •in 010 SCH-40 PVC LIGeothertual(13eatingiCooling Supply) ©Residential Water Supply(single) fG ft in,' ®lndustriaiIConitncrcial ©Residential Water Supply(shared) o RO -To 11,ATERLAL EMPLACE\IIiNTME1110D&AMOUNT ❑lnigetion • - 0 ft,. 16 ft. ' Portland Pour Non:Water Supply Well:• Dhtanitoring • .❑Rccovety ft, tt . • Injection Well: tt. rt. - . DAgrrifcrRecharge •[]GroundriitcrRcnicdiatkm I9::SANDiGItAVEL'PACKrifnipuenbl0, 'FRAM • TO MATERIA1. FMP1ACENIENTMtT11011 . DAquifcr Storage and Recovcty []Salinity Hamer • 18 ft. 30 ft. Sand ' #2, ❑Agttifer.Tcst ❑StOrnmater 13mina . ft. • ft. ❑ExperimcntaI Technology ❑Srtbsidcnce Control ' m:'DRILL1NC LOG Mooch additional sheds if'ncccssan•1 DGeodiemial(Closed Loop) ❑Tracer .FROM TO DESCRIPTION(embr.bariu n,sianenickhtaa:r.11i.*.e.dal • ❑Geotltemial(Heating(Cooliug Return) ' ❑Outer(ecplaitt under#21 RemaiI s) 0 ft. 30 ft.. Silt/sand/clay it. it. 4.Date Well(s)Corpleled: 7-5-23 •Well1D#MI-1 'It. tft.So,W�1 Location:. ft: rt. '� :s� E ' Former Cleveland-Mills • ft. IL Faciiity:OwnerNamG Facility MN(fapplicable) - ft, IL • 101 W. Main St.,.Lawndale, NC, 28090 rt. ft. ln-o ri,attt:tt ernwasra Uttt Physical Address City,anti Zip :.21:REIWARKS - Db"!:Z'3cx; Cleveland 16-18' bentonite seal County Parcel Idciitificaation No;(PIN) Sb.Latitude and Longitude in degree'cslminutcslsccrinds or decimal degrees: 22:Certification: (Ire+all field,one tatilong is silffickrn) N _. - -_ - Signature of tt �'t`v�ar::;N - Date •6.Is(are)the well(s): �Pertitanent or ❑Temporat}' � ✓. fa ..,��c�!a iir signtiia this fm,:_ .,ih•. .;rf. ac:n�t wcs I,:e,y con.rrnrcred in accordance with 15.4 NCdC 02C-'u.+9• :Ti;ir:,;;IC.,0 Ov Weil Contraction Standards mid Asir o 7.Is this a repair to an existing well: DYes or No copy ofrhix record hits been limrididtothr soil incner. rf this is a repair,fill euPkitolen well cotts7 nitloo hrfomradon and isplahr Nie tutriire of rite rerurir railer P21 reniari•.s swim;or rut the hark of this fora,. 23.Site diagram or additional will details: You-may use the back of this page to provide additional well site details or well S.Number of wells constructed: 1 contrition details. You may also attach additional pages if necessary. For tanldplc hijecrion or non-linter supply wells ONL1•with the somecnnstriallon,you con sufwnir o»a forth. SUBMITTAL INSTITCTIONS 9.Total well depth below land surfacer 30 • (fL) 24a. Fur All Wells:: Submit this from within 30 days of completion of well. For iaa$Iple wells.list all depths if(Al rear(example-3@2011'and 2@ lOil'• construction to the following: 10.Static water level below top of casing: • • (ft) Division•of Water Resources,Information Processing Unit, if water tenets above casing.tyre"+" I617 Mail Sors ice Center,Raleigh,NC 27699-1617 11..Borehole diameter.8.25"- (in.) 2-lb.For Inlection-SSells ONLY: In addition to sending the form to the address in. 24a above,also submit a•copy of this font: within-30•days'of completion of well 12.Well construction method:ESA constluctiou to the following: (Lc.at4cr.rotes,cable direct push.ore.) Division of Water Resources,Underground Injection Control Program, FOR WATER SUPPLY WELLS ONLY: - 1636 Mail Service Center,Raleigh,NC 27699-1636 13a "Yield(gym)_- Method of test: ?lc.For Water Supply&In�ection.Wctls: Also submit one copy of this farm within:0 days of completion of 13h.Disinfection type: Amount: - well construction to the county health department of the county where constructed. I Fonu GW-1 'North Carolina Ikpai/ntent of Em•irorunen i and Natural Resources-1)iviilon of WaierRroutes Revised August 2013