GW1--05168_Well Construction - GW1_20230818

WELL CONSTRUCTION RECORD For TntrnnI ONLY: •
This form can be used for single or multiple wells•
1.Well Contractor Information: •
I4.WATER ZONES
John Eisenman moo TO DP,CItIPtIoN
Well Contactor Name ft. ft. i
rt. ft.
4439
NC�VeIlConuactarCcttiftec�tiaaNwrber ,1S:OUTER CASING(focal'alit-eiscilnetls)OR-LiNERI[fep ncabk).
FROM TO DIAMETER THICKNESS MATERIAL
SAEDACCO II. fL In.
Coimany Name 16.INNER CASING ORTUBING�eoihermat erased-loo .
FROM 10 • DIAMETER THICKNESS MATERIAL
2.Well COnstructirin Permit#: 0 ft, 16 ft. 2 'M. • i PVC
List all aj.Telinahle Wetlpeninitx(Le.County.Shoe,.Yariorrce,leach et etc.) -
R. ft. • in.
3.Well Use(chat:well use): 17_SCREEN•
Water Supply Well: . _ PROM TO DiAMETER SUIT SIZE THICKNESS I MATERIAL,
ClAgrfculturai llMunicipal/Public is R. 26 ft, 2 in, oio sex-4o PVC
®Geothermal(HcatingfCooling Supply) ®Residential Water Supply(single) rt. fL in.,
©industrial/Commercial ©Residential Water Supply(lxirecl) -Fao GROUT To MATERIAL EMPLACEMENT SIErIIOD S AMOUNT
❑Irrigation . 0 ft. 12 ft. Portland Pour
Non-Water Supply Well:
IIOMonitoring . . I:Reco ery ft. ft.
Injection Well: • . ft. ft. -
LIAquifer Recharge 0Gioundw rtcr Renrcdiation I9.SANDIGRAVEL-PACKTif applicable
mom TO MxTERLSI. RMPJ.ACESIENT METHOD
❑Aquifer Storage aril?tccovely CISalinity l3aiiicr 14 R, 2 6 ft. Sand #2
❑Aquifer Tcst . QStommater Drainage '
ft, ft.
❑E.x�erimcntal Tcebnotogy ❑Subsidence Control '
20,DRILLING LOG(attach additional streets If'accessary)
OGeodremsal(Closed Loop) OTrdcer FROM ' TO DESCRIPTION Won,6nrdnett,suIVnrcktipt..RrninNit'.Nam
❑Geodtennal(Heating/Cooling Retum) ❑Odter(explain under#21 Reulad s) 0 rt. 26 . fL. Silt/sand/clay
ft. ft.
4.Date Well(s)Completed: 7-5-23 Well IDUMt't-5 ft, rL
ar sftt,E
$a.Will Location: ft. ft. �% C.,• °�;
Former Cleveland Mills ft, ft AUG
Facfitp,'OwnerName Facility IDt(if appliable) (t. ft. 2023
101 W. Main St.,, Lawndale, NC,' 28090 .rt. ft, irt.: `'O�f^f.,yF I .
PIr si:alAddress City.and Zip 21-REMARKS D eii �D unrr
Cleveland 12-14' bentonite seal
County Parcel ldc i rtnrtion No,(PIN)
Sb,Latitude and Longitude in degrccs/minutes/scconds or decimal degrees: 22.Ccrtilieation:
Orwell mild,one latriuugis salliekiit)
N W :- -_--__---- 7/7/2023
Signaturear y� 'r-�•,, cti ;�.,.. -.- Dale
6.Is(are)the well(s): 2IPennanent or OTemporary s ��`?Y€p t/. ,i's ^ » 1
B'Ai'riai•dr:t fa „ I' .I!„;6.•:, A miry r IY'�r ime:Cl'L'antrinreted hr wean/stare
with ISA NCAC 02C•'t-3'- -t..,':7 Grc�„'C..0200 Well Caarsimetio r Standards and that a
7.Is this a repair to an existing well: ❑Ye_v or EiNo cry of this reeor,i has heivi provided to;ha well mrner,
ifrhrs G a repalr,fllanttrrwrta well consinrc kia irrforrnarkat and eanlahr the nirrare of the
repair under s21 remarks sei:tau or on the brick of this foray. 23.Site diagram or additional well details:
You may use the back alibis page to provide additional well site deltils or well
S.Number of wells constructed: 1 constmctiou details. You may also attach additional pages if necessary.
For:uuttll+le.ktfeerlon croarr-ritirer supply welts ONLY.n•lth the Ruth.construction,pinto
sukmitone form SIIBMiT'TAI;iNSTLTCT7CiNS
9.Total well depth below land surface: 26 (il,) 24a. For All Wells: Sublitil this forth within 3U days of completion-of well
For methiple Wells,liar all depths Ifdrfferent(example-3€200'and 2@ LOOT Constniatipu to die following:
10.Static water level below lop of casing: • (ft.) Division of Water Resources,Information Processing Unit,
If miler liver l;above casing,ase'•+" I617 Mail Sen-ice Center,Raleigh,NC-27699-1617
11.Borehole diameter:8.25 n (in) 24b.For[nteetinn,Velly 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:ASA - construction to the following:
(Lc:auger.rotary,cable.direct push.etc:)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13:I 'inch'(gym) Method of test: 24e.For Water Supply&-Injection Wells:
Also submit one copy of this form within 30 days of completion of
well cgns[mction to the county health department of the county where
13h.Disinfection type: Amount: constructed.
Form GW-t North Carolina f)cpaamcnr of Encirorurxm and Natural Resources-Division of Warcr Rmairce Revised August 2013