GW1--05166_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multipk was
I
1.We1l.Cautractor information: '
TLIVATERZONES
John Eisenman FROnI TO DFSCRIPi1ON
Wc)l Cornragortdamc
ft. ft.. !
ft. ft. •
4439 '
NC Well Contractor Certification NwllLier :IS.OUTER CASING tforMuirl-eased owns)OR LiNER tIf'Ali tienbk)
FROM TO DIAMETER Trucureirss MATERi.AL
SAEDACCO fL fL in.
Compury Names 18.TNNER CASING OR TVBING'Anatbermal closedAaip).•
FROM TO DIAMETER intermss MATERLAL
2.Well Consti.fiction Permit#: 0 •ft. 13 ft. 2 hi. SCH-40 PVC'
List all applicable we'prnreits(tie.County.Shoe,Variance.!letting etc.)
ft. 1 ft. in:
3.Well Use(cheek well use): 17 SCREEN
Water Supply Welt: FROM -4 TO DIAMETER 5GDTSt7E TIIHN ICt1S I MATERIAI,
CIAglicultnlal DMunicipal/Pltblic . 13 ft. 1 23 ft. 2 fir► 010 SCH-40 PVC
OGeothennal(Healing/Cooling Supply) ©Residential Water Supply(single) ft.'IIIII ft.
in,
OIndustrial/Commercial OResidential Water Supply(slued) lelSioGirRO TO MATERIAL en[PLACE\IENT.rrernou SAnlouNr
'13 Irrigation . • 0 ft. .9 fit Portland - Pour
Non-Water Supply Well:
ft.
f L-�iMonitoring .1Recovery •
Injection Well: ft, It.'
OAquiferRecharge :GroundilaterRelnediation 19.SAND/GRAVEL PACK ofupplieabte)--: .
FROM TO nuert;Rtal. ` FiMPi.ACKAIKNT S►F:rurn►
❑Aquifer Storage and Recovery °Salinity Barrier 11 ft.. 23 ft. Sand #2
❑Aquifer Test. ❑Stormwnter Drainage
ft. ft:
❑Experimental Technology ASnbsidcricc Control
2o:'DRILLING'LOG(attach additional sheets-if accessarvl
OGeothennal(Closed Loop) ❑Tracer FROM TO DESCRIPTION rmbr.hnrdne.s,wilrocklpt.'aralnwe.de.1
°Geothermal(Heating/Cooling Return) OOilher(explain under#21 Retnatks) 0 ft. 23 ft, Silt/sand/clay
ft. fL
4.Date Wags)Completed: 7-5-23 Well IDt1MW-3 •
a ,.o
ft. It.
5a.�Irdl L(lc►thm: E-� ! �-7 r.."
• Former Cleveland Mills it. • ' ft. AUG
Faciiity/OwnerMute , Facility mit(if applicable) I, rt. �0��
101 W. Main St., Lawndale, NC, 28090 • ft, It. ir,`Grtr�, q'3;4..v�1((•,Q Lint
Plti sisal Addtass.City.and Zip ,2 1.,RI M lXS
Cleveland 9-11' bentonite seal-
Comb.- Pared le:nlitioillmn No,(PINi) -
5b.Latitude and Longitude in degrecs/minutcs/sceouds or decimal degrees: 22.Certifirntion:
(Ilneit Feld,6.k6,161.1g,is srdllcierd) -
N . . W . ---_ _--- - --- 7/7/2023
Sian tun:a ."r. 7ar1,.ra'e:s s- "-__.,,—.--,— Dale
6.Is(are)the well(s): 81Peomanent or DTemporary. 1,10t(' . ;C7-�sZT:i. - -a�s �
Br signing this fut.r., e1.� �xE c.�.rn�+p.r.q constructed in accordance
with 1&l NC4C 02C.• :., -1.::.i 4,e4 vdC..O2O Well Co ish7IcNOR Standards nod;hat a
7.Is this a repair to an existing well: °Yes or ENO copy of Mil retool bhs bran provided ro olio urfl`lever.
If this is a repair,fill oat,troicn well cons,,u atoa information god esPtabr the ti12r.4rt of the
repair ardor tit!remarks srcrian or on the bad of this forer. 23.Site diagram or additional well details:
You may use the back of this page to Provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
Formutriple ngketInl or ormi-ii'uter supply weth ONLY midi the.santecotrstriwlton,you can
salmi:one form. $CTBkITTALINSTLTCTIONS '
9.Total well depth below land surface: 23 (ft.) 24a. Feir All Wells: Submit this forth within 30 days of completion of well
For,uahiphr iratfa,list 4711 depths ifdlftirrent(exaoipfe-.1€:rift'anti 2@ WD(t y construction to the following:
10.Static water level below lap of casing: (it) Division of Water Resources,Information Processing Unit,
limiter keel is above,using,use"+" 1617 Mail Service Center,Ralc gh,NC 27699-1617
11,Borehole diameter,8.25" (in-) 24b.For Infection Wells ONLY: in addition to sending the toms to the address in
24a above. also submit a copy of this font within 30 days of completion of well
12.Well construction method:HSA canstmctian to the following:
(i.e.sager..rotary,cable,direct posh,cm)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of test: 224E For.Water Supply&injection Wells:
Also submit one copy of this form within 30 days of completion of
131b.Disinfection types Amount: well constnietion to the county health department of the enmity where
conducted.
Form OW-I North Carolina Department of Envirmumni and Normal Resources-Division of Winer Resatrco Revised August 201)