GW1--06398_Well Construction - GW1_20231009

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WELL.CONSTRUC'ITON-RECORD Far Ward Use{ONLY:. It`
' tThis•forincan,be moil rin ineje*tiatliiplawas• • i. ,
1.►Yell;Cbutt:ltor In$Ornlation: . •
--141LWATLRZONES" - . & . .• .
John Eisenman tti0M TO. -miCitIPUI0 N '
• well CoriiraclrirN Noon. R: ft.. I
4439 •
-ft. . ft,. I 1 • '
• NCWCII Cararaclarc ni@�uot Nwdicr AS:AttTER=CASiNG(kitinnd Izin eit'ricitsl'ORL1NER:ftraO'tky61c1- <- .
FROI ' TO PrAMETP.n' • THICKNESS MATEMA1.
SAEDACCO t4 fL 1, in
Cuiupur)Nauu 1d:1NNER.CASiNG OR-TLBING( iailninitictarci1441') :-_ ..
FROM . -TO DIAMETER THICKNESS YIATERIAL
2.Wct1 Construction Pctuiit#: - 0 -ft.� 30 ' It, �2- 'iL ' KN
SCH-40 PVC
!List riAnpp1i(74k 194! eOri is(i-r_.Comuv,Suilr,..:Varia:Variance.kial7`4;0 J'
R, rt. : ill .
3,.:WcllUse((beef:yellrise): • • • • • ;i7:sCRELN .
Water•a'upply WO: - - FROM. 10 WAMETER' s LOT Sin- T111(1cSI S 1 MAI-mum,
®rlglteul[tlial �11411inlcipaalJfltb)iC.^ 30 ft, 45 it; 2 'PI .010. SCH-40 PVC ,
- tIGeotbetmal(HeatingiCooIing'Supply'). (lResidentiaGEYater Supply'(single) ft. ft:• - in. - . •
t8°GROIIT _ .
DhidusirialJContotercial ®Residential liratet-5u ': •.pp1}'{si>tnd} FROM Tt). ' 5LITEBt1I ESIPLIC£1IESThIEi11QI1.LA�fO[NT
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. . Elkrimition . . 0 •ft.• 24 It. Portland Pour
- Non=WaiterSupplyWO: ..- . -.- .
11hloottciring Catteeosiety ft,.` rt;. - _
• In,�l'CIIOR�yCll: •
• ft, • .ft.'- I.
' 13Ar{utfcritcciiarge 1.1dinutdwiter•4eiacdiatioa :t4:SANDJGRAVEL••PACK iflipOite bter:—_— --7,_ - _:
. . . ;PROM TO mATMU.I - .ksiPI AcinwNT uuirtlpn
. EIAg11tfcrStoni catxI_Recat'e ' .IJSaliniti Aimcr` 27 tt. 45 ft. sand. #2
ElAriadfcrTat. t7Stoinisiatcr1}r.,i nags • . . . ft.. I.e..' I .
6Ei petinuotal rcchuolo .. . C75itbsideai c'Controt • -
26:11RILLI G'1:OG(iittath addliioniil sdcets if itieeisi iiil
.DGeetitennal(Closed Loop)- DTracer '• . • FJtOat- TO - DEICRtlmON raobr.lr lydatti,:uarl
rock a. :trrcn OWN-H.
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DGeotltennaf(IieatinuCaolin -Retuni} 13t]Iiter(e'cpjriiu underfk21-Rewatks) 0 .tt, 45 It, ,clay/sand
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IL. • IL ri _
4:DafcWel(s).Comtipietcd: 9-2i-23 Midi ID#MW-26 ft. ft, l' '"�'z^u 'l q Y d
5a WO I ueutUirn: 6 K,s 'q._. b
f4
Ingersoll-Rand .- =- :-- ---. " - . - . -. ,ft.'- - =r1:' - ..
-. — . OCT_.0 9.G023
F•actlity101vncrNmuc Facthrt}•iDt(ifappl,cabla), R. fti' i111i:Tri 5'^• r c '• 31.rP. . •�. r 1
• 501 Sanford Ave., Nocksville, NC; 27028- . ' ' ft, ft, CVAF,yr
• . • Floiiratl Address Cit).and Zip` ;2 tc REMARKS' - - -
• Davie • Bentonite seal 24-27' ;- ' -
Cmmny' pane]IdetritrttCatlorl Nu;(TIN) •
Ali,Lititude'anifA.00ngtmmiiein dagrccs/niinutcs/scconds ai•dcchiul degl :'. 22 Certification: is ' -
(if well ftekt Doe tataen tii,snit',cieid) -
N- -W ,°' _ -- - 9/29/2023
. Sigmtrireaf -.'`Itl.1i4nnii. - VDaic
. 6.Is(are)the'rt'ell(s) �Cimaneat or :3Teurporui'11' - �! �, yy.� 4,s{ ,i f" fa- ?l•. •
lh•aignii,a 1 ax Jfat;'r�uy A fl,�r�:h�•A. �•Z'.I J�y..e:.l cwrsrrucltvP Jrr•rxY•orvkmre.
WIN ISA IVC+AC ate -+ n �te•;0,00 WWI Cr?rrarrn:iinil SraalarttaTid Mar<T
7.As this a rep11ir to an existinj clif- ' DYe or EN') rt-4?rbfdlts iarotyibiiskc'u penis d i:5{Jaesn ii cin ir•
-1f this.f o repr0Jr fill car fiavna1 ls•dl a»nin+uc han hrforrnnrk rn cin;J euptaht slir,riarnre of the.
ripair &r.i'2l.resnurkllsecaeuri or iv:ihie bink oftrio form.. 23:Site diagrata or additional n'elI details: ,
You tua}use Qie.back of this page to:prosideadditonal•II.ell site detailsor'Isell
S:ilriluherof K'ells constructed: 1 constwction ileiiils..You ina}als f atlacli additional pages if te.'cessaty.
ForinattipkeIrtfectroti.irrtrrnlinrersup h'weiTs.O?,LYirJtfii/ie.scrm ecmrstructton,.youtwo +, '
• SGG9.111(hie jlvrm.. - " - - • SEIBMITTA 1.I NSTUCTIONS i;
¶ TOt twelldepthheluiwiandstirfae i 45 - (iL) -2.la. Fur All Wcllts Submit this'farm tyithin30 days'o!Coinptciloti'of writ •
For irenlrlptci4.(!s'J(3raftdep.*if61fferrigtxrrn,+re=? 2ik'I'a+ul.2@J00) consttnctiontotIv dossing; ' • ' '
10.Static H•uter fetel below top of cmrinid . (ft.) -Division of WaterRl oil cei1,lnformutipn K pcessing Unit,
1j11xitev),,,i.ei if aLoeu mshan;iisc +' 1617 Mail_Senrcc¢Center.It:dclgh?i1C•2769J-IG'17
11,Borehcite diameter,8..25" (In.) lib:Far Infer;lort�Si[i ONLY: �iri addition to'sending the form to the address in'
24aahiii0..also submit a,copy of lids font within 30••del's'of completion of II'ell
12:_Wallconstructinumethod:HdA consinietiou in.die follossuigr j
au :kw,kw,cable.duect push cm.} k
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. Pivisioir of Water Resourecs.Underground injection Coutrbl.Pnugraui,
FOR WATER SUPPLY WELLS ONLY' 163-6.hinil Service'Ccuter,Raleigh,NC276994636 -
u3 Tt'icld' Alctirod of tesk '24c,For Water•Suf1NF&tnicction Wells: . '
' dl;{►ul) • Also submit one 7ctitty of this four Within.0.4,'sofcotnpletiou.of
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I3tr.Diylnfc tinn•typci Amount: wed-constmctioa to the county health department of.the-county where-
- constnicted.
Fonu,GW-t Nook Carolina llcpaltnentofEtn'iromuenraadNatwal1csaurccs-DivisInuofWarditBwtret - - , - -Rcs'iscd.Augus32013,