GW1--05167_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORD For Imernai Use®NLv:
This form can bz'uwd for single or nuiltipk wells
1.Well.Cautraactor Itformatlon: ,
`14.VATERZONES .
John Eiseaman Most TO 'OleiCRIPTION
Well Coraraaor Name ft. rt. 1
•
4439 It. It.
NC Well Cammcmr Caniflr�lion Nunil3et 1S.OUTER CASING(for mitt-aisellnictis1 OR LINER(if an Elcabk •
. FROM TO • DIAMETER THICKNESS• MATERIAL
SAEDACCO IL. ft la
Comput•Nam ld.'INNER'C ASING(IR;TUBING`tggethermal closed-pomp)..
' FROM TO ' • DIAMETER THICKNESS MATERIAL-
2.Well Constl•trt:tinnPernnit#: o ' R. 15 ft, 2 ' 'tn. SCH-40 PVC
L sttrllapp&able will penitits(ce.County.Sudo,Variance.NeL'Dfsl'esr..l
. ft• rt. in
3.Well-Use(cheep;well use): 17 SCItLLN -
Water-Supply Well: . • . - - FROM TO DtAMETE ' SLOT-SIZE TIIICKNFSS I MMATknfAL
. ❑Agiteeultstral IJMunicipal/Pubfic 15 ft. 25 fr. 2 ilkono SCH-40 PVC
. DGeothemial(lieating/Cooling Supply) ®Residential Water Supply(single)' It It. in,
©LndustriailConunercial ©Residential Water Supply(shared) t8:GROUT
FROM 70 ' MATERIAL EMPLACEMENT SIEn1OD&AMOUNT
❑IrripOtion . ' . . 0 ft, 11 ft. Portland Pour
Non-Water Supply Well:
PilMonitoring DRecovery • R. • ftb
• Injection Well: It. ' ft. ' •
,
CO Aquifer Recharge Of3roundwtierRentcdiation -19:'SANIItGRAVELPACK(ifupplicahtc)': ..
•FROM • TO arA•rfiRWl; DIN.Ws:HENT 5IITlIOD
ElAtinifcr Stotago and Rccgvrty ❑Salinity Battier- 13 ft. 25 ft. Sand #2
. D Aquifer Test. DStorntnatcrDrainage .
ft. ft: .
- ❑Experimental Tc hiiotogy DSubsidencc Control
`20 DRILLING'EOG(allack additional sheets if accessar 1
DGeotl&emtal(Closed Loop) ❑Tracer .FROST TO DESCRIPTION twbr.!iamb c.rl,soir,'mrckIttme'trai AAA;elt.l
❑Geothermal(FleatingiCoolingReturn) ❑Other(explain under#21Retuanks) 0 It: 25 f4 silt/sand/clay
ft. •• ' ft.
4.Date Wcll(s)Completed: 7.-5-23 Well IDpMW-4 • •
ft. rt. F g9 v
E-;. %
Former Cleveland Mills It, ' ft. AUG A I IC 1
Facitity,ThsncrNati!e • . Facility IBM(if applicable) • R. ft,. Z � -
101 W. Main St.,.Lawndale, NC, 28090 ft.- rt i4h„r,7nsati'rm?1'r,^-t r��IR
ili
Physicai Address City.and Zip �2t.R12WAWKS D1P,,C t3Ck
Cleveland 11-13' bentoni,te seal ' •
Courtly Parcel ldaniifis.1llon No,(PIN) ' '
Sb.Latitude anti Longitude in.degrees/minutcshccrinds or decimal dtgtets: 22.Certification: . .
(itweit acid,olw Ia41oug is sandal')
7/7/2023
Signature of r: vuiut" ,----- —
Date
6.Is(are)thewell(s): 1Penfanent or • DTemporary l. ,ss. ;f ,.r >cx!a
!lr signing this fm,; P'l; .:.e.,th,. tf:i: r.. r 1 nss Ir:e.g euns meted in necardonce_
'with i S,t NCAC 02C.1.,,,-717.:.:TCA: t rC.0200 flWF CoustrocNoa Standards and that a
'7.Is this a repair to an existing wells DYe s or ElNo may of Mir record has Neel pisrided totlrr.rm-ll owner,
• If th(s Is a repair,fall drat.hoc n i well cctAftntCtlotl Lrfonatn)o,r did explain the aware of the
repair wafer P3!remarks section or rat the ballot this form. 23.Site diagram or additional well Retails:
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'.
For',au ilple bjccrlon or oar-warer supply Lints ON!.)' ikh the same.caustrirctiou,~hit Can
salon:a One form. - •SITIDMI14PALINSTCTCTIONS
0:Total well depth below land surface: 28 ' (f1141 24a. For AU Wells: Suhileit this fowl within 30 days of completion of well
FornrultipleWellslistalldepthsIfd(di,rent(exatarple,3€200'atu12?(0A)' eonsimctionto the foltoving:
10.Static water level below top of casing: A) Division of Water Resources,Information Processing Unit,.
Ifutrtrr level is abate ceoltag•use"+" 1617 Mail Sen'icc Center,Raleigh,NC 27699-1617
It,Borehole diameter.8.25" (in.) 24b.For Ipject on WON ONLY: In addition to.sending the form to the.address in
24a above.also submit a copy of this.form within 30 days of completion of well
-12.Well construction method:NSA - construction to the following:
(i.e.angcr.rotary,cable.direct push etc.) Division of Water Resources,I)nderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:' 1636 Mail Service Center,Raleigh,NC.2 7699-1636 •
13a Yield(pm) Method of test: 2;e•For Water Supply&lnjection'Wells:
Also submit one copy of this form within 30 days of completion of
Bell construction to the county health department of the county where
13h.DisinfcYtiuo Over Amount: constructed.
Farm GW-L Noah Catalina Depunmene of Eneiieiuo rn and Nauman Resources-Division of Water Rewtron Revised August 2013