GW1--06399_Well Construction - GW1_20231009

1YELL CONSTRUCTION RECORD '�� For(trlenialUse ONLY: '
1114 Faun can be used for single,or multiple wills-
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I.�YelLCoutractorinfornlation: \ ►► \V —
N `I4 WATLRZONES'
John Eisenman Ftto31 I To OESCRtPilON
W 1I Contractor N7nti rt. rt. [ '
4439 rt. rG `
NC�S'c1ICon1(aclarCertificationNturlict 'IS:'oUTF�tCe1SiNG'(f�iimulti=caved'nelisl`ORLiitictif'dti'lkabk)`,• ....
FROM 'I in PERM.Ttrn TOICt ISM MATERIAL
SAEDACCO fL I IL in.
('onrjctuy-Namin I6 INN Eli:CASING OR'TI.IBUNG'i eatbirmarclaied-li.li' '' - > ,
FROST TO DIAMETER TIiiCKNF.Ss MATERIAL
2.Wcjt Canstrtlethiin Permit K; 0 ft. 30 ft. 6 'En. SCH-40 PVC •
List rt!I appliroble well prnrrfts(Lc-County.Stoic,Ira►iaare,lrfalrit r;etc.1
3:We11'15s'('Mail.Well rise): :I7:SCREEN
Water Supply Well: - - -- FU0S1 I TO DtAMV.TE;R SLOT-SinT1tUCl(Yt;SS I MATE IU M.
❑Aglicultutal ElMuniCipal/Public 30 ff. 50 'R. I 6 4. .010 SCH-40 I PVC
® rm Geotheal(HcatingfCooling Supply)' 17Rcs"idential Water Supply(single) ti' ft.. i"'
CIindusirialCoamlercial - IJResideatial\YaterS,upPly(slot�ed) 38 GROUT ;- :
FROM. TO. MATERIAL EMPLICESIENT3IETHOD&AMOUT
❑Irnpa)tion• . ' 0 ft. 24 ft. Portland Pour
Non-lWaterSupply Well: ' - ft, ft.-
nivionitoring '6dReefolety • . - _ _- . _ .
Inection Weil; ft. ft. .
❑AgttifcrRcchargt: QGroundssolcrRcincdiatian r19 SAND;cRAvH1:r.+C>ttirutrlitil=t,t;:t - = - --_: --.= . . . -
- PRg3t . .To 31ATF:tirA1. -I1PLCENIENT4lI atoll
❑Aituifcr:Sioragc and Rccoicty ❑Salinity Barrie ' 27 R. 50 ft. Sand #2
ID Aquifer Test. ❑Slotimlatm'itntinigc - --
•
ri. ft.
❑k erirncntal To hnolog. ASnbsidcncc Control '
.2tt:DRILLING LOG`tallach additional Sheets'if aeecasairsl
DGe tltenlud(Closed Leap) ❑Tracer 1114031 TO DESCRIPTION(colir.hiuducn,millinick type.trrall sva cH:)
❑C1 otltemlal(Fleming/Cooling Retu n) ❑Ot er(explain under•.#21-Remarks) 0 ft. 50 ft, clays/sand �^
�.Date Well(s)Completed.: Willp1#Rw-04 ft.
ft. "+� �'& A���• ��
ft. fL .''Q m r' �e.• N.,,2 ,
.J
5a.Well Location: • .tL ft. ' OCT n A 2
Ingersoll'Rand -- .-- - . - . R. •ft. -- tj
Facilily/ChrocrNaatc Faclity ID#1appli able). Inf--.:tire= :.all 1 _ •
._.rave.
501 Sanford Ave., Mocksville, NC, 27028 4, 41, • • .
Pb}sirad Addtcss City-.and Zip -21.REMIARK5
Davie • • 'Bentonite seal from 24-27'
Camay nice]td atiliication No.(PIN)
5h.•i ittitude audit ngituilc in dcgtkcs/minutes/seconds nr decimal de1,n•ccs: 22.("clTihienti(rn:
(If a ill Bei(a,ante latiloit is sailliienl)
N 'W -- --' 9/29/2023 9/2023
•' L ~ -Sigmture oI 7 ;i ^cs.. - • Date
6.Is(cre)th.weU(s)t.$1PerniIiitt ,or fTemporate . ,.. t.. '10f6 (' _ sV �aY's . ifvi'.` J. cn 1now1.:F i7Yr/fCrCI1R.:GCLV 1I LT
with 15A-NGtC 02e-+x-, , t3.F Cti::..7 C,0200 Well Ct»utnrarimr Standards sold then a
7.Is this a relaairto an.cxistiagwell:' tlVes or 111Nu 'tevr_of OW Crain-1;16,4cm pprr•ided to.the WI miner,
if thls:ls a repair fail rapt known Weil onigr caul infor,1ar:wr ion1 explain the?ware of the
repair raider la 1.remarks seruan or he the hark bfthis faro(. 23:Site di igrarn or additional riven details:
You may use the back of this page to;pros'ideadditional well site details or*ell
8.Number of wells constructed: 1 construction details. You inaealso attach additional pages ifoccessaly.
For nrartriple infecrlon or aim-waxer sarppty(veils ONLY yeJth the mate eonstnmrFoet,you rtmra
se(amlrone farm. SUBMITTAL iNSTLTCTIONS
9.Total Well depth helot'land surface 50 (itt} 21 r. Gar ALI Welk: Submit this form within 30 days of completion of well
For multiple wekllsr all depths ifdiffer:infe;xoarpia'-:i€+200°atul.2@FOal) consintction to the following:
1
!0:Staticwater level below top of eusiuir • ({l,) Division of Water Resources,Information Pnacessing Unit,
if note,leue/Is above(situ;,itse^+•• • 1617 Mail.Si-rice Ccntcr,Raleigh,NC 27699-1617
ii,Borclmtc diamcter.12.257 , (in.) 24tt.For 1ttjtaction Wells ONLY: 'in addition to•sending,Ih►e foal to the address in
24aabove.also submit a-cep!' of this Sono within 30 days'of completion of well
12.Well construction method:ESA catlstluctlon totllc followine! ; '
(i.e.auger;rotary,cable direct push etc..) L . .
. DMyioit of Water Resources,dlndcrground Lnjeetloli Control_PrOgranl,
FOR WATER SUPPLY WELLS ONLY: 1 636Mail Sen•ice Center,Raleigh,NC 27699-1636
13;1,lucid(#(i>u). - Method of test: 24e..For Water Supply&Injection Wells:
Also subnut one copy of this fonts Within+()dayrsofcouipletion.of -
13h.Disinfection t pea Amount:' well constnictian.to the county health depatiment or the coittlfy where
-. constructed.
. 1
Fenn GW-t NorthCamllnaD panmcnrofEnvironm ntandNaturalResources-DirislockofWaterftnotro Rer'tsed August.h)I3