HomeMy WebLinkAboutGW1--00449_Well Construction - GW1_20240116 y
WELL CONSTRUCTION RECORD Far[Mental UscONLY:
This Form cam bc used flu singleurmultipk nclls
I.Wtdl.Contrattor:fnformation:
1:WATER ZONES,
John,Eiseman .. . . FROM TO - 'DtSSCRIPTiON
Well CotpiadorNatate R.' ft.
4439-A. :fit. ft. I .
NC.WcilConlracl6recdificatioiNmntier • 'OS OUTER CASING(foiloufit:eisediiells'YORLiNF.R(Willi ncabrels -
FROMr - TO -. DIAMETER.'- TItICKYESS- MATERIAL•
SAEDACCO iL IL. 'Iim.
Company No a - t6:INNER CASING OR TUBING(geolhcranal closed-loop) '. '
-FROM - TO• DLATIETER. , THICKNESS MATERIAL
• 2.Wel.Constrtittion Penult#: . . O. ft. 69" ft. 2 . ' in. SCH-40 -PVC '
List aIta plicatrlewellpeimits(LIi.County;S5ri'•Uorinuee,lry'e idan tc.). .i4; R1., _ ; ,_�, , ,
3.Well.Use(chccl:�r°cll use).: .t7:SCREEN '
Water Supply Well: . FROMt. . TO PrA)IF.ThR ,SLOT SV.E THICKNESS- I MATERIAL• .
17Agttcaltutal • o• MunicipaUPttblie. . 69 It. .74 lt: 2 Ili :oio SCR-40 I PVC
17Geothetntal(Heating,'Cooiing Supply) • CIResidentiai'Water Supply(single) R' f. in
Dlndustrial/Conui[ercial ' DResidential Water St ' (shard) IS GROUT
GROUT. - �p�' 'FROM'. - TO . ' . '.MATERIAL'. . - &PLACEMENi'M'ET11OD&&MOUNT
• Ofriipation . . rem .0' '.ft.. 65 •fta Portland- Tie '
. Nau-Water Supply Fell:..
n. "ft.
l Monitoring t7Rccorrry.
• Infection:}Veit: . _'tG' ft, . . . • . : . -
1 L golfer Recharge ClGiouridaatcr Reniediatiori :t9:SANDIERAVEL I ACh(ifavant-abler. - ,
• suOM( • TO_ Mt tTRRLII,'. f%tPI I%lr NT NI4TnDn
ElAgnifcfStorage and ltcco�ct}° ']Salinity p imer 67 R,: 74 It,, Sand I ' • #2
17Agrrifcr.Tcst. ' ElStormw'itcrf}ntgogc:.
LIEkperimcntal Tcchoolo y EISuhsidcncc Control .
2D:DRILLING'LOG(aivacb additional sheds if=neccssarsl
t7Geotheimal(ClosedLoop) 'OTricer. . .FROM TO . ' DESCRIPTION feobr.hardncn,wuwkenti. aiawe:ttet
I3Geot enual(IIeatingtCooliug Return) • 170therdexplain under#Z1'Rethinks) . 'rt.' tt..
• 4.Date`Well(s)Contplelcd:'12-14-23 :'QVcllHDNMW-9- •• �.� ? . '
$a:Weil Iaicatinn: �' •
rt. tG-. • 1 tl e+ g 3
$2.50 Cleaners . ft.' tl, JAN G' LGLf
Facrlil)',OivncrNamc. .Facrlit)•ink.(ifaappliwblc)
•R'` it itlfJFa a-ti2rl P C'-‘:C.-.5'craiPst 1)u
2785 Charlotte Hwy., Mooresville, NC, .28117. _t. . ft: Dire;(;/oG
Pltvsi;:idAdiiixssCiy.andZip'" 2t:REMARK.S' . ' . .
iredell bentonite seal 65-67r _
County Parcel Idcnlileation No,(PIN')
56isaiitade'atidiringtudeisdegrcec1minuteilseiondsordecimalagrees 22.Ccrtiticatinn:• "
•
(itvii;II field,of ,latdoria is supfcieni) - ' " I
• N • N f:.l: . __. 12/22/2023
Signittirnaf i-.,,,,I til"..i a ,-" �_ . .Date
6.Is(arc)the nell(s):.%Permanent. .or fTemporat} ' li 'sa -rcva c
11}�aignhrg rhir jaa,R�r� if��'1.,...�+'t�.v ,.i�:li)v/Lf t a:f:eJ commuted at 4YYttfi1m1CC
nith15ANCAC!cc:;tom.;- o't c'n�Sdti.0200RrUCoarstnttlwrStondardsaaadtina
7.Is this a repair io en existing well: CDVe,• pr AND 'rtrt%vnjrltu rrronf.has hcen provirkd rave hell new e,
IJthfs Is a iepalr;fill cot kaoava wdl coos nfcrforrl' rrrutlinn marl rsplahu•dr amrure of rhe,
repairri,der$21 itia s ra s sraiio or Mt the Leak of d,ir form. . . 23.Site diagr'am'or adtiltlta lfalf well details: • . •
You niay use the back of this page.to..provide additional well site.details'or.Well
' S.Nirmherof wells copsiructed: 1 coustiuctioridelaifs. You-may:also atiach'additional pages if tiecessaty.
For anilfrllale Glrcilmr or inn-unfer iuppfr wells ONLYWth'fie same roastnrcriest,yoai.rgn -
sulonitr ne form.' - - Sf1Q)N[TTAL iNSTUCTIONS- i• .
9.Total well.depth hetow land surface: '74 • - . (fit.) 24a.•For All Wells: Submit this•form within 30 days of'completion of Well
Far rrcuhlplc'relish's?alIdeprhsffdl,6,inrnt(crmnp7c-3O7PO°muf.20IPS) • construction to the following; • ?
10.Static water level below top of casing:" ((it,) Division of Water Rciourtes',informa" tion Processing Unit,
if uwler level is above cast ag:ate" " - 1617+ Mali Serrice Ce•nter;8elei y NC 2 769 916 17-
1I,Borehole diameter:8.25" - -(in.) 24b.For rnjecen Well ONLY: in addition to sending-the font to the address in
24a above,.also.submit a copy of this'faun within 30 days of completion of well
12.Well construction method:HSA - . construction to the following:- '
_o.auger.Dainty.cable.direct'piish etc.) t(i -
'Division of Water Resources,Underground Lnjc celattt Control Program;
FOR WATER SUPPLY WELLS ONLY: • 11636 Mail Service Center.Raleigh,NC 27699-1636
13:1 Yield(gpm) 41ctllod'of test: '24e.'FdrWater Simply&Injection Wctli:
Also submit one copy of this fain Within 30.daysof completion of
131t.Diainfeetiun type: • Amount: . well constnuction to the county health dcpartmcnt or the.coiiuty.wherc
constructed.
Font GW-1 t-odh Camilla Dcpanl them.of Ein1ionnUu ant Natural Resources-Division of Water Reso Remised August 2013