GW1--00149_Well Construction - GW1_20231229

+ WELLWELLCONSTRtJCTION 12 CQ D FarCrscrnal Use t3NLY::
- This.form can bc used for singlcofmultiplettms-
1.%Ndt.Coittrytctot l ttorn itk rt:- .
`t:fi-WATERZANES .
John Eisenman - FIWM Tp DESCRIPTION
Well Contractorl`.irna, . . . ft. ft.. I' ; • •
4439-A-
ft. I • ft.
WC Well Contractor CetiificartibRThurber `tS:OtlTER CASING'tfurmuttli'M tlriells1 OR LiN} tiros tieabki•e- . - .
GIt4M • 'IF TO DIAMETER THICKNESS MATERIAL -
SAEDACCO
H...I it. I', la.
Cooisoi-Wom4-. MANNER CASING OR TUBING eibrrinJ csuI.lio ••-
FROM TO . DIAMETER THICKNESS'c MATERIAL - '
2.Welt Construction Permit#: 0 R, 20 . IL- 2 I., ' lit. SCH-40 PVC -
• Lirtufl cpiilicobr.:war pOrtits(Le:County,Sttor,V,riarare,TrIr2L0[4 'c.)
3.'Welt.Use{ehccl,well use); -•17;ScitEEN .
Water SuPPEY Welk ' most TO DIAMETER SLOT SIT.) TRiCKNI=SS SIATRR/AI,- -
PJAglicttttutal ClhitirliclpaU'I'ttb):ic. 20 ft. 30 ft: 2 i+t 010 3CH-90- PVC_
' t ICer thenhat(EicatitiglCooliug Supply) EiRssiitlenlial Water Supply(single) ft: 1 rt:. io`
. . ClIndusiriallConui ercial ©Residential Water-Supply(shared) de'GRO1T1 -> - ,4L :. - - _ _..
FRONT •TO: ... NfATErttAL - i EAIPLACESIEITSIETHOD&ASIOUNIT
El irrigation . . . . .. . . 0 Yt.. 15 . •ft, .Portland Pour -
?oti N;tfet•Suttpl}`Nell:
6llhfonikitring DReco.NVtp ft,. h. - . .
Injection Weil: —H. fa : I'
LIAquifcrRecharge MOroundwaterReiltediftiou 19eSANBJGtttVEL`-PACKYilajoiliithbtil"= = -_:_-_-= ; - -_
•-yttoM TO " NIATr,RraI, •tMPLACEMENTMETHOn -
tJA01nfcr-Stvragc and Recn�st' y, • DSalinity Harriet` 18 (t.- 30 fa Sand I, ; #2-' -
• ElAgutfcr Test CISlornMatcr l3ntliagc � it,.
❑Rxpctinicnlal Technologic. EiSnbsidcsbcc,Coifirolft,. i •*1li DRCI;LIirG�LOG'(nit,ieti addliiiaoal ilkit if ireeeisart•1'-' - • ' -
. CUG:othettttal(Closed Loop) ❑Tracer FROM , TO - I)CtCRIPTIiDN ft»tir.l,i tinc o iIIPtsez hix.:srun sri,tiFl
t3Geothennal(fleatine Cooling Return) C7Otlter(explain under:#21 Retuaths) 0 .IL. 30- .ft, clay I' -
f6 - .ft. !' _�
12-15-23 MW-2' ;
1.Date�i'ell(s).completed:" �Vcil I11# ft. - IL ,m ' u i °�
sa;'Wig Location: .ft.' ' r4 DEC 9 9 2023
J
Maple.Hill.Grocery ft. '0,
racnii}10;}ocrNag FacilityIDk Cfapplicuble)
rt, ft..• • •' 4
1009 Austin Traphill,Rd,, Elkin, •NC, 28621. , , • ft, . ' . ik -
Ply-s,eiiI ditdicss city,and Zin' J - , -
Wilkes , bentonite seal 15-18'- j • -
Caurrly - - Parcel IdeilliffeatlonNo:(FIN) -
•
• r•
Sb.)'.atitudc and l>on);innle in degrees/minutcs/seconds nr dseint;il dtgrccs: 22.CetTlftelation:- - '
(if n llitchi,ourI:W10uF,1:t•tifianit) I'
`N -- 12/18/2023
Sigtt3turclofF}'v-r: fl.7 ilU,0 .;;— �'' _:— "Dale
6.Is(tine)the-welll(s): EIFerin mutt or t]Temporary try signing this fahis ::%C, i(✓tt,• :4:: f;4 3wr-r;meted to,oprorgooi e
*irhlS,I NOW 02C:x - t.,; i4+tW..,i. 0200 Well Coirsrr+crioirStarxdaalsirndrhMr<r .
7.Is this acepairtuaneiristtn yell:- 'oyes ,or ❑ND cagr.oftWrm-riniliiist-nifinnufdra.theSn.11rimier.
If rhfs is a Vt fill r n isrmtai tr i raturriictivA lrrarrn trial rrai7 r:tplain rhi iu,wre of rile 1'
repairrarz(ere121:rernarf.iarrma ocivl Ate brraiL pf rllir form. -3:She ddillRrani"or additional well details: .
You.may use the,back of this page to ptouide•additiotiat well site details.or Well
8.Number'of welts cot netted: 1 . - -construction details, You May itlsli:ailacItadtGUonatpages if neeessaty. •
•
For Orfilrl&.ittferrlon'ur rtrni-maer supply wells ONLY illt rhr.saiaecmestrurfton,you(legit
• submit one -' SIIRM111'A1.1NSTUCTION8 'l -
1 •
9.Total Well depth Below limit stiti'aee: 30 (ft,) 24a. For AU Wilk: Submit this form within 30 days of anuptedoti of welt
Far,irathlplet4rllslstalldtphs ifdlfrria&maple-Z@?1)lVororl.2@KW) constniction to the Coltonting
10:Static water leiiiel below dolt of easing: - (ff,) Elvish*of-Water Re.sol trees,Infrirniutif n Processing Unit,
If inter tcri1)s Ohm's riasioa„ilk'"t" 1647 i41atl.St Ice/tenter,Raleigh,NC 27699-1617 •
11.Borehole diameter,8.25" an.) 24b;For efecttatt Wells ONLY: in addition to-sending the fomt to the addres in:
24a above,also sUltmit a•copy of this forte within 30'daYs'of completion of well
Il.Well construction method; BSA construction to the following: I I
(ic-auger rotary,cable direct rush etc:} -
DtvCSion ofWatcr Resources,[ludergautid Injection Control Program,
FOR WATER WELLS ONLY 163614Li1t Sens ice Center,Raleigh,NC 27699-E636
C3 �'fcid(ltitgl) •
24e.,For Wati:t.Supply.&lniec1ton Wells;
,I, Method of test: Also submit one•copy of this•foriu;Within-30 days of completion of
Il3U:Disinfection type: Amount: well construction to the county licalth department of the county where
. constnicicd.
• Form GW-L North Carolina Dcpannuent of Environment and Natural Resources-Division of Waler 4ott Revised August2013
I