GW1--00148_Well Construction - GW1_20231229

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WELL3CONST RCJCT[ON-RECORD For tactual Use ONLY:
h fonii cam,bc used for single or multiple weds' 2 \
I..� elL.CoutomtitrInformation: a
:t1E{YATLR ONES. I.John Eisenman LcIW I. •rcr h SCnlPTlt)N
Well Coritracior t.one• R. ft. I I '
•
ft. ff. I I
4439-A •
TtCWc17Cautfactor�crtifecativnNuttbcr 'IS 0UTEItCASING ttierifultJ,a J;eetisi'ORLINl R:Wan-lientdcf% .-
• tor TO DIAMETER THitt.NESS • tirATr,R1AL
SAEDACCO R.. ft. , i Ile
Company Nauc ;t6.-INNER CASING QR-TuBIING:(erviticimal cinkildou,p) .'-_._..' ' '----
PEON' '10 - DIAMETER THICKNESS MATERIAL
:2 WCA Const13 ItliII PerMit d: 0 R, 20 • ft. 2 1• IIISCH-40 A PVC
• l iti till applicable 1.e11 pennitc(it.Counts'.Stu.c,Variance,II)'PC07e1 etr..) •
f1, rt. 1 frt
I
3:�Yc16 ilsp(Cited:well dl use)d L7at atdEN .
-Water Supply Well: ER--- i la DT%METtip' • SLOT SIZE , TUIcxNFSS 1 MAI-MIAL
C1elgficuhntal D)4[tillicipalil'uUlic 20 R. I30 rt. 2 in. .010 SCH-40 PVC.
DGeatheltttal(Beating/CoolingSupply) ©Residential-Water Supply(single) ft
• • I ft. .hi,
ClIndust ialfComntercial ©Residential Water Supph'(sill red) tsz GitOTJT€ _ •
PROSr TO. ' 1ihTERt L &P1.AC NIIaN `iER10A R A51oQ\T -
• ❑iTipation- -. , 0 'ft. 15 ft. Portland Pour
flan.%VaterSuliply Weil:
�lvloniioring Ol�ccntVly ft, fl
• Injection Well: R. ft,•
' 9AquiferRecharge I IGivntiiluaicrlteincdiaiion ..192SANDlf;RAVI.'LrACt liruppuennter ---- = _ = --- =.:.--,- = - .
-"FROM .10 MATP,urAi, • EMPLACEMENT NIL'r1I01►
a Aq)niftrSiotagc and Recovery , O5nlinityRarlice 18 ft. '30 ft. Sand #2
. CI Aquifer Test. OStonMratcr,Drtinapp .
ft.. ft. •
C]Expetimcntal Teelntoiogy. ASttbsidcncc.Corttml . .
10:URLL[.ING 11:OG7attueWadititionat sheets if ttcer'ssirsi••
DGeuthennal(Clesed.Loop) ,©Tracer 610151 TO PESCRIPTIUN'(rotor.ImWn cm.•Naliptck Dix.grain Are.dr.i -
tlG,othenn at(Ell atingiCoollttg Retwu) 17Other(explain under 4121 Rematbs) 0 .It. 30 ft.- clay
it. ft. '
-I.Date Well(s)Completed: 12-15-23 Well iDllMW-1 R. ft.
Sa.Wdl Location: ft. h.
Maple.Hill Grocery ft. t( ' V i
Facility;thV erNmec FactTty IDk(ifappiicable) R. R: n1c':CI
. 1009 Austin Traphill,Rd., Elkin, NC, 28621• R. �.
Pllvsiedladdles.City.andZIp • {2t.RErtimmS • . - . .1-at,..•- "'',:::J1Jn
Wilkes • bentonite seal 15-18'' "�'
•
Conuty Parcel Identification No.(PIN) 1
5h,-I.;ititudcand t,ong(mdein dcgrcestminutcslsecnndsorsdccimn[degrees: 22,Certtificatitetu 1,
(if unit Held,one tatloiu is sufficient) .
;
IV W _„';yiJ. 12/18/2023
�.: _ _
. Sigmtureofj $wi si::WaY.ii ''- "— hate
6.Is(are)the weli(x)t XlPertllanutt or 9Tcniporai}' ity sd in�� AvY•G;f! fa' J rg. aurntrneterf he.acrorrl,-nce
with[5%ACtCOW•12.- - 1' ;-cA,C,r.C,0201J ifellCousrrrn•tron Srooda,<fs and that a
- 7,Is this a repair to an existing;well: 9PYtui or DNt) &n n-ofthis ieein!inn &Wl(Unrifled ron'H••Uri/tinnier,
If rkts k a trl crlr fill om knt»idi redf a amtntctlori hrforenarlon rod explain the nature of the .
repair under p2l'remark.Lre-tlnn ur iw site bark of thirtorn. 23:SLte.diagram or additional Well details: •
You may use the back of this page'to:provide•addifional well site details or Well
8.Nuntherof wells constructed: 1 consirtiction details. You niay itlso attach additional pages if nccessaly.
Forrunitlpfe.Infeerlon or non-water supply wefts ON!.)with line smugcotrstruretiotr,you eon
nabeilt one'form. .%MittITI'Al,1NST(JCTiiONS''
9.'iiotal hell depth belo*land stirfacei 30 • (ft.) 2,f t. For Ail Welis: Submit this.form within 30 days of eomnptelion of well
For Toll/plc u4rUr list all dcpthsifdifiurnrfc.uunpfe=.T@200'ami.:bs!0(r) constntttionto the fotioniug: I '
10.Static�vatec level below top;of casing: (R.) Division uf'Vater R eioureeS,InfnrmutianFrocessing Unit,
1/rater level Js above ceasing.use••+•• 1617 ALai1.Servie i Hooter,Raleigh,NC 27699-1017
it.Dorehrife diamcfcr:8.25" (in.) 21b.For it 1setlorr'Wolfs ONLY:i In addition to sending the foot to the address in
24a above. also submit a-copy O f•this fans within 39 days of.completion a ttull
12.Well construction method:HSA constriction to the following! ,
(i.e.anger,retarp.caMe.•dircct Fush sec:) 1
Division of Water Resources;Underground ftijectiou Control:PtograB1,
• . FOR WATER SUPPLY WELLS ONLY: 1636 Malt Service Center,Raleigh,NC 27699-636
13ao,Yield(g{imy Method nicest: 2:le.For Water-Supply&[rejection_Actis:
Also subuiit one copy of this foot Within 39 days of completion of
1311.Disinfection tppel Amount: well construction to the county tic alth department of t[tecounty where
constructed.
FanuGW-1 North Carolina Depanmetof Environment and Natural Resources-Division of Water Rr=atrcm Revised Atuu -2 t0l3
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