GW1--07671_Well Construction - GW1_20231122

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WELL:CONS TRUCTION RECORD
(-3( Fig Intetnai I.4c CINLY:. I. '
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This fortn Cilli.b •uk:19 ref-tingle&quitipk voila.- . -
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I .r
I.Welt rCnittiattot"Nforniatintn. c c)"----
• \\.)•\ . 4, =t4.:.:1V-ATE RZONES.. - •• _
John Eisenman 'Fitottl- TO " On.SCRIPTION
%Volt Contractor'Name, ' , 1.3.10R: 20.00 ft. 1 •,
• „ft: • . .
. . 4439 . . . it • .t) I i . • . -• .. ''.• .
NeWell Contractor Ocrtificationit Ninef : , . .,.,.. ._... _. .. . , ,.. , .
',ISAPUTER-CASING(for muttiksstantils)OR-LINER liraonticable). .-... • .
• FROM ' "TO • .' .DEAMEITIR-- • THICKNESS -- MATERIAL '
SAEDACCO ' • . .
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- Computi-trante, . • •. . l NER.C .2iiitirItUed-lon'Tli
-FROM -TO DIAMETER THICKNESS MATERIAL
" 2.'WCIleol.tirtitt1fiii Ocratit 4:.N/A • • , • 0 ft. 5 ft.- 2 1: • .Itt- SCR-40 PVC • .
Lift rill repit4Iols-ill perFiti:4(ic.-efutioy.'POlfi.,VOria.ltie.ity-ettk4 07..1'.
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' " •fi.: - Or '1 f1?.i ,
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• • 3,\Vit:i.t5 -01etir:iiillu.sei • 47:SCREEN • . .
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Water Supply Weill ..uson.- . TO DIAMETER,- SLOT SITX THICKNIZS 111ATERVAL Ii
. ' • - '• - ' 5 R. 20 'IL, 2. !0.. .010. SCH7 4 0 , PVC
ONgitculinial - : biOinidiptiPnidie; . ,
. . . CIGtothermat(llealiktiteofiRiSt141.: ,1:11iesidenlial:WaterSopOly(single)• ' .fi.'. -. .1.!•'•• ', -1"'I . .. ' - • - " *
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ClitiduStriateCOninteiVial, CIRes4entiat Water,Snpitik(snared). '7'•':u,R0` m .T.46'. , , 'Iv'i-k-TER—TAL,'-7':-::
'I EcA-PEA CEMENT SIETIF.i0D:SIAiliiiINT-
CI frripation. _. . . -- - • ' ; 0 ;ft.: 3 . . ft.- Portland Pour
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• - - •NTIAIV* 1•I r WO:' . . . -. . . . .. . . ..• . . , a . . . • . . . .
%.. -. ' ' . . • . ft.- At: , ir
6610111106.1.*
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• Ittleettnn A-Vet ,t: . .
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ciA4i0faritc0i0ge .. • . cliditujidwarcjgcloediaop . • %.t92SAND/GRAVELPACRiirimili6kbter--: -.-- -----7,.-----.::---,-,.. -..• , ."-.-..,-7'. -,
• '. . -.:. .. -:. • : . FROM - -To',.-• 1 rtIATEntat. . - EMPLACEMENT METHOD
PAtitufgStoragc.ani I.Egcciyeq. 0$...0u-1513-0,404 4 • R.: 20 R. derici;: ' • •
#2
El Altar Test 1:1SOittili.at&O.t;iiipge . . .
. . . . . . • .... . ... . . fL. . -k- • ' -!
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ii *pciipiental TeeltriOtp.O.. ItilStibOdencet6iiirpt -
. . ,.... ....211•:DRILLIINGIOGItittlehiddlticitial ilieetsifitikeisadt'1Neetitetitutf(Ouse4 Lpop) • • intt-dept. • . FROM,' -TO ", DESCRIPTION(e)be.hanItittil,v0Flitek OM,sari OM de.)
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EIGeothenttat(fleatineiCaolineRetun0 : 1:10ther(explaitiuntler42i-Retnoths 0 t ft,., 20 - -- S
ft.
Silt/sand/clay
s cla ' .•. . / 'ad, yn i '
. . ' ..ft. ft,. , :-- , .
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.. -t:Dit te NVett(0):Conipktd::'9-12- *di IrD#14.P1-3R . . 1 . -ft... .. , irt. • .: • "
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- . Si.71Veil,LOathni: • .
ft..- ft. • ,
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. .Arlington Branco Oil-Company . • . . . - . ft.. . fr.•
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- - tictlitykDyner'Name ' ' FicOity OM(fSppl#144e). i'll 4
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• 270 N. Main St. „. Jonesville,•'NC, 28642 • ., . . „ . . .
-.. . It.,. .ft,- - . - .- .,• , • •
tnc;;-:,-.:-..'"'31:-''-' -••:,•';:'. .•111,13:i• •
• • tilcilf•Ai445;Otk-'•*.Ai,. -32.1::-REM-ARES'. •
Yadkin . . 123134 'bentonite seal from 3v I.-4'
CO1ally' - • Parcel It,ientification No;(81t1)' ' . • 1 .,
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.56,..1,...atititqainil:LoOkittittle In tfcgraihninutisisconils or-dschital -.22.eirtiffeatiotir . ' 1 •
(if moll rp4t4oxie iattlonfl is..iiittlekatt) • - . `.. . • ' •
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36.22980 As,- 80.83914 • NV
. . .Sigu3tare -.1.,:47,...h -,....
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6,Is(Ore)the_Well0): 71Pernianent. .'or i±itenaporaiy ?-1R•ji,6•,k.,..:,1.,p:../.1.-.e;...7.4,2 _,,- ,.
tix 4giieii8,,,,.t jus..!:4,-.. ...,:..j..reftero ti,....:_,V1i i6:,4 zr.,r4Imilcu otAt'aMancr
*irk 154 Ncite 02C.1.4- -if-i=IN:....k::..-.i'...7C-;i1200 WO gem filletign Standards rind thee a
7-fs,this..al relisiila an e..i4lingiv.ell i:-.11401, or .RINo cs7.0.1this-irri.iiii 114 iltell priwided iiiiimmislt inink
grkti..fts;r4terfr fill(ttrkirAcit vOilivrakimethmi&hi rniarhinrind&Main thoriawre of the I,
'itiOrrir raid&021:renutrits seodrin or- '1 rho hoile,of this form II:Site diiigrani or atdd,itiotuitwill..:41epiftst . •
. You ma use Rie..bach-of this pa to...prpvidelidditiatiat well Site details.'or tiett
ti.liumber ofWelis eonstnaeted: 1 --" ' -construction'ileiaiN: You irtay it4):A4icit idditiotpllia•ges if iteeesslity.
koe.litafideg hejO.00.-,-4-•trati-ioritee supply ll'.4'l(i ONLY nirh rite gains coin frier/iv',yon AM
5:01iitt.00 Prod.- ., . SUBMITTAL INSTLICTIONS
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O.TOOliVell depth 1).i:him-land sttiflice.: 20• .- - . -. " . (ft.)', -Th. Pot All Wall .in''.5filintit ibis forth within 30 t -of IcOinpletf40'Of nta
i'or ntrillipic gislist ail depths Ifdiffi.ron;iitiorripte-3€100'arni 20.149) 'constniCtiwito the&Wiling:
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13.10 DtvEshitt of'04iter Re.40ticti's,1Eiftinitittititt Itt-ti essiiig Mitt
• ip.§tailie:ivnter lei'et ItelOW too of easingi O.)
. . 1/to kketis oiove.casing irsi."+" 1617 Mail Service irenter,Raleigh,ls1C276994617
il borchOie diameter 8•••25" _ _lin.) .24h.For halm*rt Well ONLY- : In addition to send*the form to-the addms- :in.
. 24O-ab&e,-.also sub nut 4:.copy of this.form sr Rhin 30•dals of completion of welt
12,Well construction method;HSA . comittictiou CO the fbfloOrini!: 1 •.
(i.e.*gar,toigo,,cable direct posit.etc
. . DiviSiott al WOW ResOurscF,Piniergrottittiftektiatt CordiOl PrOgrant,
yoRwATIERSUPPOT WELLS ONLY:. 1636 Mail Service Center,Raleigh,NC21694636
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. 24c.For Water'Supply.&fidectiottiWetts:. .
13ittNiFid(giint) l'ilr0.11tod pf 5*z
Also submit'oRe.eoj3y of this'fchrti within.'30 days completion of
'13h Diiufegt ,well,cOirilnietiOn.Co the county healthdcijartinent of the:coimty•wheie
.. siou,tip et Amount'
in .
constructed, ,
Rum GW-1 Nortkomlina fkimontentof Environment attei Nantral ft.cw urcca-,%vision oiWate Recturc .Rei.i.scd August 2011