GW1--07356_Well Construction - GW1_20231113

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WELL CONSTRUCTION RECORD' FutbecrltuluscoNly: '
This Conn can be used Rif single or multiple wells' 1 S )
1.Welt.Contractor Information: •
IL-WATER ZONES- . _I : . .
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John Eisenman • PROM TO DESCRIPtI0N . '
' Well Contractor Name ft. ft. 1, '
4439 • ft. ft. I
NC Weil Contractor Certification Nairn& 45,OUTER•Ce1SiNGlformvllt=eiseiliieils)`ORL1NERiif31i tic`IMfel. -
•FROM ' TO DIAMETER, THICKNESS MATERIAL
SAEDACCO • ft. ft. in, •
Company.Norm. - - I6:'INNER'CASING ORTUBING eoiterzaal closed-loop),". . .
FROM TO • DEARIETER• THICKNESS • MATERIAL
• 2.Well,Construction 1'er'nrit 4: 011-18-MW5-RWO 0 'R. 13 ft: 2 I' •It4 SCE-40 PVC -•
Lid oil applkubla ur.Upehldts(ix.County.State,:Variance,Infection err,)
ft.. - ft. 1 in,
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3.Wcll.Usc(chccl:r;;c11 use): I7:5CRD N
Water•Supply Well:. - - mom ' TO .DIAMETER •St.OTSI7,F: - -TiIICKNFSS STATF.RIAL
t]Agricitlnunl ' • CRvfunicipel/Publie • 13, ft. 23 ft. .2 • in :010 SCH-40 PVC
. ❑Geothermal(HeatingICooliog Supply) . ❑Residential Water Supply(single) . IL fL an.
. I Ilnduslrial/Comniercial ©Rcsiilential'Water Supply(si iled) 18' •GROUT.- . . _ •... " ..
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FROM • TO - MATERIAL EMPLACEMENT`iEiHOD&A�fOUNT .
❑ltripation - •- 0' ft. 9 ' ft. Portland Pour
Non•Wafcr Supply Well:
�Manitorinr - °Recovery . R. to
• Injection Well:. . ft. - ft,' . I - .
• ❑AquiferRccllargc DGoaundwater Renicdiation °-I9tSANDJCRAVEL I'ACK•(if aplillcabtcl':- - -
F'ROM ' TO • ' SIATEIUAI, F$IPLA(:'FAIENT irrtron
i]Agniter Stolagc and Rccovety. []Salinity Ranier ii f.. 23 -CI.' Sand' #2 • .
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❑Agnifer.Test . 175(0mmitcr Malang' ft.. ft: li •
❑l:Ntienrricnhtl Technology ❑Subsidence Control.
-20;DRILLi11G'LOG'(allach additional stieda-if-accessary) . •
❑ rnGeathe al(Closed Loop) ❑Tracer PROM- TO DESCRIPTION Kobr.tinrdnc+v;autl'r;,ektrtx: in simile.) ,
❑Geothermal(Fleatine/Cooline Return) . ❑Outer( plaint under#2l.Retnad s) 0 .ft. 23- •ft, clay,
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ft. .. ft.
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' 4.Date Well(s)Conipleied:'10-26-23 Well IDfMW-19 ft.. ft
Sul.Will Location: ft. ft. `4%..e. i da v )) '
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Buckeye SE Terminals, LLC •
fb ft;
JJOV 9
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Facilit)-OwricrNatiic. Facility IDx(ifappiicable).; • R. ft. # �
6907 W..Markat St.. #B,. Greensboro, NC, 27409 ft. It. A,:u..-,",;'- t, ..
Physical Addtcss Cit};mat Zip [i•,:; -, {,.•,. '� ••
. `2 L REM,kRKS",
Guilford Bentonite seal from 9-lift
Comity Parcel Idciiiiticttlon No;(PIN) .
Sb.I»rtitiide and Longitude in degrcec/minutcs/sseonds nr.deciin d degrees:' 22.Certification: I.
.- (If ri'ell6i.ld,caic latnongis sufficient)
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N • W ------- . 10/27/2023
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• Date
. . . Sigtnuire'a' -/7,tio,�e::,.. • _
. 6.Is(are)"therscll(s): .NPerntancnt. 'et". 17Tentporaiy irysigi,;d,hiir,fn,4r2'.1`i i—.'1l, ly',:,nsr? 1. ti �Yta'e,nvrnreleditr,acadrthince-
• with FM NCAC 02C- +-�?-.l 7i- C'i'1:,r;„iC-A20P Well Constrncrion SrmtoVaisandrlariia •
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7.IN this-a ielltiir to an existing well; ❑Yes or IKINti .copy of[hit i-oral has htcii piprJrled tin iha aril muicr. ..
ifth6a 4.a repels,fill oar kiit,iivt 1ni1 coru7ruellaa hrfommriou arul rxpfaln iha rurrare of the •
' repair cinder d'3lrenapntvstraian'oronthe bark ofditrfor„r. 23.Site diagramor additional Well!lentils:
You may uSe the bad:of this page to provide additional-well site(lt ails or well
8.Nutnberof wells constructed: 1 construction details; You trial.'also atlacb'additiona1 pages if necessary.
For timitdple i jeerlo,i or nrut-i a'r.i apply iveffs ONLY pith rite stove emrstractio,r,you ern ' 1' -
submut one forth. . . SUDr4t1TALINSTUCTiONS ;'
9.Total well depth below land surfacei, 23 (t't.) 24a. Fair All Wells, Submit Ibis form within 30 days''of completion.of Well '
" For trtihiplewedlclsraUl depths ifddfferoO(eraa,ptc-3@200'aiul2@1OO' constntction to thefoiloning; '
10.Static Water level below top of easing: • (ff,) Division of Water Resources,Information Processing Unit,
if water lekel Lc above casing:use'+" 1617 Mai S 'ice C,:entcr,Raleigh,NC 27699 I617
11.Borehole diameter:8.25" On.) 21b.For btfeetion Wells ONLY:, in addition to sending the£omi to the address in
2$aabase.also subnut a copy of thus font'within 30 daYs•of completion of well
12:Well construction method:HSA c'otlstmcilon to the following:
(i.e.auger..miary.cable.direct pinketc.) -- i -
'Div'ision of Water Resources,Underground Injection Control Program,
FORNVATERSUPPLY WELLS-ONLYe - .1636 Milli Scrs'ice Center,Raleigh,NC 27699-1636
13a Yield(gjinr) 3lctlrod'of test 2d�For.Water Supply&'i jectton Welts:
Also subnut one copy of this faim!,within 30 days of conlpletion,of
13b.Disinfcetion type: _ Aninunt:
well constntction to the county Itcounty calth department of the where
constricted. )I
Fanul GW-t North Carolina Depunn eni of Enviroitrnetn and Natural Resources-Divisloa of WaterRe3otrCes Revised Auguit2013