GW1--00478_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD Far 'crnilt7scOl?Ll:
This forth can h6 ased.tar siugtc ar multiple wells \\_)\
I.Wi i-+ivotttracter fitforntatiou: •
\IL---\
\t1 VATER2ONES . . . r , .
John Eisenman • FROM 10 DESCNUPr10N . i .
Walt CurAtector Name f t• ft. ' I
4439 It.' ft.
NC Well Caiamciar.ccnificatiouNuiter ;1.5Z OUTER CASING'ttailatutti=disiil'eIrsl'OR:GiIYERtitAi"tka6k):'- --
.&ROM TO DUA34ETER I ',THICKNESS, . SfATE TIAL
SAEDACCO • ft. ?C ! IS. _• •
• Cmiyi;uo. are 161NNERCASING.GRAI/R C:° iiiheinia1ctuiedeliioe Yr' . .. -- • .
. SROSM• TO' .- DIAMETER INICKNESS SIATEfL1L
2,Wctr(anstfuetujn FeEtut U: 0 •"ft. 10 ft 2 'it. SC1140 PVC .
•fistuil,z #irabk.wel rimitsti-r::Goon Stain,tforiamrr;1- 3Qfil,ctr,.J - . .
p - �?','. . . ft. • !b ..
3.Well.i3so[cltrCli)Yell usc): 17:Sd ttEEN . -
• Water SulgilyWd1 — _ mom•. ..TO 1 atAsn+'ri;R, sit►YSIZ.E TIC"rf.NItis mArfitamt
ticlgneukittal iDMtimcipalll'tthlic to 0:, 25 it, ( 2 in 010 SCH40 PVC . •
®Geothemtal if ieafingtCooiingSupply)-- l Residential WaterSuppi�'(single). ' u' ft. . - -•lu' I' '
®rndustdatJCokimiefciai D1 c tdetitial Water Supply•(sliatrd). s.FROM• 'TO • i MATERRAL- . EMPLI.cEctNT StENIOD c AMOUNf
❑iritOtitian'- .- - 0 ' ft. 5 -ft. Portland' Pour .
lkotl WaterSuppty Weth • .
• (2h(gnilpvin R.: fit: -
R AR�o�•cf}• '
•rttJectiat6 Welt'• .•ft, ft, • i.
IAgttrfer Recharge flGioundlriier Rcittcdiation. . •s t9:SANDIGRAVEL.PACK at aiipllilitc)' : _ - .
;FROM- 10 • M:MIA AI.• EsiK,AC*%tt r mtriton
• LIAijitrfcr.Stotagc end. tccGveiy ASallnay tumor• 8 R: 25 ft, sand #2
. 17Arinifcr Test faStor*nwfler ftraitiogc l
• 'ft.:. . ft.'
❑k 1 et ttler1 al l'cchnoio y t 4141)0(ICOC.Carorot
10" IRILLIirGIOG(iilimkridititiiinat.isheelalt'reeinaKr
17Grothemiai((lasedLoopi..• t7Tracer• •MOM. -. 10 ' •DESCRIPTION hoknhanin,si:iur0.mektrr�; , sYe.dset
. DGeodtetncil`((rearing/CoolingReturn} . 1:Outer tesplai u.under#21 Retu tds1 0 - _'ft. 11 ft, sand stone
• 11-. .ft.' "25: • fr. rock , . p .
�:.I)ate WO)Gotitpletcti: 12-21-23 Well lt1 #MW-4 . . .•
ft.-. 1 r"N . •
,ter
;a,Will lirmcatinio: ft, ft: ! �n
. rt - •I .. 6 2024
EactlayAlist erNantc. Fe7it)liiP O applicable) ^it, lnf r�r iw� r, ,,;1 ip;• 4993 Plank Rd,_Norwood, NC, 28128 - ' . -it, ft, �.Jv ;�: •
Plq's eill Addis.City,and Zip' 3Lb7tEBIAINiS,
Stanly . bentonite seal from 5.-8ft '.
Camay patrol Idesaik;ltlynNo,(PIN) -
5'
Sb,i.a#itude'and L.iingitrideIR ilei r'ces/irtiituteitseconds ar dceiti al degrees: .22;Oei'tifctttutn-, ,
• (lftrett field,ate latilomiS cull ti a) - - I '
• ,-f .
• `fir ---- - — 12/22/2023.
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f
. Signttur^ ��I.,e.''-1 U', —i Date
6.IS(sr&)the went*); �1?content or DTemporar)'. fs �'
tf azgmtrd rhir fail: r7% •'..:;try ' :.� n.,t�Js l.e:r1 iNatt uctedt ht mrotrfanct•
mi'ia.15rCiYCr1CPIC-1.4..,.4� "ie.A.: lti.028.0llettCouieritionSiorufrrds and tint a
. . 7.LF this;a repair ta an 0.i-ttin):well: . Dyes or gehTiQ coili rlilr rreonl hak ben'(irni'idi.1 ra,10-urlltnvn'i. '
ifthis:11.o'repair,Sillour Aninrmirrlti,00rltircitorrilrfriirr rjoutuali pkth rl!erurtureofMe •
• rrpcirmurdrr�f.nenords•Swetioriwrrvtthie&..t ofrliirfnrmr. <2.Site dutlirainor additional Well�4L'tatl.9t
You may,6se.tlle bad:of tilt;page.to provide additional well site details or Will
8.Manlier of wells enustrueted: 1 - coustmction details:'You may also attach additional pages if uecessaity.
• For rtuiltipte ltafectlori or ririti mint.a smrpply leigh ONLY.withrlic shore.ewestnral rr,you r4O
•subutir one fnrrv.• ' SilDMi1TAf?siNSTUCTIONS' 1
9.Total well deptlthelorr land.surface: 25 . - . di) 24a.14ir ALL-Wells: Sitbruft This form Within 30 days'of-completitiu of Welt
For,tuthiphr keels lls'trdl1cluhsifdljli*.ia(example-3 .00'and2isWY Constinetionto.titcfotloising: 1. -
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10.Static water level below-top of casing; _(ft.) Diiisiou of Water Re'snurccs,InfitrmutitinPrucersin;Unit,
filmier lruel is above cwsfrag,Cue"4." 1617•MLtLL SeiNicc Ce ter,Rtleigh,SC27899-1617 -
I1.13orehoLe diameter:6 _ (ilk.) .24b.Mir I leetiop%its.ONLY: in addition to sending-the fotnt to the address in
240 abo e.-also siibtitit a copy of this-forth within 30 days of completion of well •
I2..Wcll construction method:Air Rotary . ,construction to the following 1
(ice auger.robs}',cdble,deert push.etc:} i .
1)tt'Lsfott Of Water;Resources,Underground rnjcctiou Control I►rOg sin, .
. FOR WATER SUPPLYWELLS'ONI.Y: 1636 Milt Ser%ice•Cater..Raleigh.NC-27699-I636
24e.For Water SRnelt&Inieetion WeLhe
I3a;Yteld(uilm) Meth od'of test: ,
Also'submitrt one copy of this fa tt ithitt 30 days.of comlleiiou of
13v.Disinfection 83Rcr Amount: Well construction',to the-county health,deportment of the County where•
constructed.
Form GW-L Noah Condom Deponmciitof Eiwiron nerttattd Natural Resources-Dicvloa of Water ttesou'[es Revised Augtst2Dl3