GW1--07672_Well Construction - GW1_20231122

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*.ELL CO NSTRUtTEON'RECORD- .
For livenui ifsc131:11..Y:'.
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Th(s.foritt cap bc-used fa sitigkat nudtiple wills•
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.I.WO.Ctinte,letot•-Ittrorttatiott:. . . . . . . . . . •
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John Eisenman ESOIG. '10 DESCRIPTION •
SV'Ol CoictractikNing. 13.8011.- 20.00:fi. _ I . . •
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. 'AS'iOUTEICCASING'tlifiliiiittPinninfik110'OR LINER:tifriti RANO'. .-...
NC Well Coldratot Certification thorber .
6110M.: - ' TG - ,DtAiNIETER,, THICKNESS ' , TITATESTAI, -
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SAEDACCO . . . .(tt: (L• . l' is.
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• FROM -- TO D/AMETER• =CT:NES& MATERIAL
2.1Wet(tonitruftlon liertnit li: N/A . 0 'ft, 5 ' •ft.. 2 . . -IX SCH-40 PVC
Life at/aiyiligible if-eillies*ftx fi:i.qufilty;•4•triti,..Kirlatrre.freettti4 fk:)0.
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3.Well-lit (t!!4-k 'ci!use)
. . • . 7-17;.-SCREEN - • • • • - • — .• .
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. . Witter Supple Well:' • .- ritolir, , To _ DIAMETER SI,OTS171:• TIIICKNIS
5 -ft,- 20 'ft. 2 4. .010 SCH—4 O PVC • .
. laAgtionliittal. . C,JIAtinicipal/Pitblie:: • . ,.ft;. . • '-11, - • • . . .
IGeotitermaklieating1COoilot Snooty). Cliitsi'dential Water Supi)ly.(stogie) • - . •
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Clluclusittal/Coninterciel '
CiResidentiRt Water Supply•(shared) -1 •5/ ' . • - --s-- ' -
•.To. • MATERIAL • 'ENIPLACE,HENT METHOD&AMOUNT
' f3Irrigatibn' , . . ' • . . • . . . 0 • ft..-: '3 :ft, Portland Pour '•' • . • - .
NcittAArati•Su.tiltly Weil
07,19tlitOtrittg: - • - -Olt ccOYetY' - ' - . - .
. • ,Ittjeeitott Wollt• . . . it,
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. • . PattuiferR4hatge' - Ofitotilithratcr Rontedialiou - 19.1.S41101GRAVELTACRitliiiiiilieahttr'.-
••PROhl. Ter • - m.A.TrattAt,- .tottet..totwoi:NT Mkreirto . • .
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PittfulfcT; ttir4Ooticl Kectrf.c!)'. PiSalinity ElOrtiet. 4 . ,ft".: 20 .ft. Sand • #2'•. \.
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El Aitifeitcit. 1:181aunninct=ifitainage . . , . • . • , • . .. . . .. . , • . . . .. ,
. . . ft. ' - •ii6petintental TOIntotome • . 1±4tibsideKc:Ctit)ittlil: • - • , - ' • .
10:DRILLINGLOGIlittaell'additioiiiil'Sheaf ifikeee:Ssa-01:
120eOtheintat closet Loop): liTracer, - ,FRIDI- , -TO '. DESCRIPTION(color.hardtomit tik ollik htiatiii
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EIGeolltottnatillearinatoOling-Retum)- 130lIter.(explain undet#2i-Retuatlis) .: 0 ft. 20 ' .ft, Silt/sand/clay - •
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.. 4:.lia6`Weit(s):Conittletedt 9-12-23 Will 11D#W1-1st ' . -- .fc "' • ft. •',, -
- . 54.Well Litclatfoti: ..rt.. ft. - . . :- ', ,,—,(..,./.,i----...i; V•:1'.::,3_,'
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Arlington-Branco.Oil Company.. ' • . • ft.. ft,. .. '
N f ILV_2_2_2023
FicilitglyiynerNaitto- - - NOW i.OR OfraPP*-1444... - •
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, - 270.N. Main St. ,. Jonesville, NC, 2 8 64 2 . (t.• . ft, 1,.
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P11.01c19 449`.55,CitY. .. flt.RENT/MKS'. - • . ' '. •
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- Yadkin . - . 123134 . -bentonite 'seal, from 3'174'
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County • , - - . - -. - , Pareelltatificatiso No:(kg) " • . . .
5ii.11.iititt.144Hilt LOBO:B44n ii*ceittninttlis/siOnd ti.1 -dschital:(100ii*• ,22 ci.niff6litiort:
omen f,atd,elk littileeg.4.,sm:016:111) . - -- '
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36.22965 N 80.83889 ' W .......4,5.:::f.„.,..,--<;._-----,...„ -'------ 9/17/2023,
• • SiOntum(p.:941 ---‘7„---. . ' Dile
6.IS(Arr.)ithe."WilKs}t /Bl'eintaitgat .or OTeutporaty
• 4 Aigoiiii:thiyAiii47.7,44).'.:6;,11.46,449:44a1.4t7i1•1;..Z71,0,.4.inlereyi fik wean-timer
. . • • iiith'f M'ATC4CO2e. -:/..-7:1TC.ic,.4e.,02047-11i4 et Cmisinecifim Rori4rfds mid Au o
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' *7;lis this a smiaii-fo an eiciStingwellf, pVes, or ,111tkin viii2-.7.9fribt...t•ioccinf kii,i:tifen Otivvideilii die mg!vitli4 r.
•If th(s:h 0 4,Alii'..fiii Or'40(dtd liVird.,d7dimrdad hrbroii-eriOn aid tiErkihr rho itarare of rho . •
iitvir ruder!021.i-rnarld.Aittiria pi'd.7 f&•bal(-of thisfornt. • -13i8ite tliggrant•or.athlttionat Well tiotaiits: . .
You ma use the,haek of this,page t0Inovidiadditional n:41 Site.details or Welt
8:IStattlieeilf n'ellstnittriieted: 1 . ..
' r . . Cotigilliq thin details: YOtt may alsOattitpliidldhionot pages if tieceSsat±i:
. . For riudriligo hecriliniii rum-mcirer.sigiply iv.,e(49NLY•fildilhi.safttreoustrtfittlatt,you eon
sOntifth foriii. .SUBNIrlirAL-NSTUCTioN •
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• • .9.1FOLit`Weil ilpfli lieloiTland StirfaOn: • 2° , . . . .(my. .-.00i. For AR.N.Valif Submit this;ftnut withitt 30(Lays'of,etimpletiOli"of Well -
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ear altifiripte wdls14P all depths ffdlffem):laurof pie-3€12fKr awl.263,1110) . ' consIniCtirm to the foktonits-, r 1:. '
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10.Statie.water leihel lteltne.top.of easing.: 13•80 • (It) division of Water Re.41ifreis,fent-math! Ptimessing Unit,'..
IfIviver tof:ol ii i2brive eq'sk*;iise"+" 1617 141ail.Service tr'.titer.Raleigh,li117659-1611
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11,Borehole(hamster:0•25"• '(in„) 11b.--For Infgetig ni Wells ONLY: In addition to sending the form to the idnass in
IN&Or:*also submit a:8O0y of this faun within:30•d4s of completion of Well
12.1irchiconstruction method:HSA _ consnuction tothe folloWina:• 1
• (La.auger,total),cal;,1cdirec1 gustvctF.:} 1 I . . . .-
• " - ' . Rivhiloit of Itlititer iiisourcis,11, ildeiground hijecliort Control Program, -
FOR WATER SUPPLY WELLS ONbitt 1636 Mail Serke tlCenter,Raleigh,NC 1765941636
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.24e.Oor Watei Supply.&titleetion:.Wetist
• 0 3a1,-Iflqd Witt) Wilma.of test»
Also submit'one copy of this form Within 30:03. 0rconigletiott of .
1134..Iiis!nfeetton,trpct Amount: ' wca:cOIWRICticlo.to the county health department of the'county where constructed.
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Ferni GW,1 NOM Corolla Dqaronetoef Bill ami Manual Resources-Wfilos Of\Yam Rientro4 Revised August 2013
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