GW1--00479_Well Construction - GW1_20240116

•
WELL CONSTRUCTION'RECORD For 1criu1 Use ONLY:
TIi{crib can be used for single or nnritipk wells
I.Well QAntrtetur Inforutatiou: '
-LL ATLRZONES •
John Eisenman FROM"TO DEscnIP11UN
Well Contractor Nanie ft. ft.
4439A tt.' ft, I ,
NC Well Cantiacior Certification Nuirbcf 15:•OUTER CASING(fotm ulll=evee8'iticllsl'OR LINER ltf a`tii'Tkie61W.
•FROM . 1 70 DIAMETER , ' 7IIIEKNEs5; MATERIAL
f4 i
SAEDACCOft; •lu.
I
Corepoi hSmq: -t6:INNERGASINGORTUBING(i,ietherrunlctu%cil-loop))"•' _
FROM TO' DIAMETER •Tt1ICKNESS MATERIAL
2..\Yell Constructioie Permit-0: 0 ft. 35 ft. ' 2 1 ilk, SCH40 pvc
fAO allalryilirable well ponriti fi_r.:G'orrn%Stdte,Variarrce.fi}'a ri rn rir,.) ' ft. n4' -
3.WdLtisc(checlewell use): _ 17.SCREEN.
. WitcrSupply Well: • FROM• 1 TO otAMETKR St.OrSin TIUCKNt S- I MArRrnM.
L°Agricultural C1)bluriicipaVPub)ic• 35 ff: 45 ft, 2 in, '.010 SCH40 PVC
' DGeothemlal(HeatingtlCoolingSupply) ®Residential Water Supply(single) ft• 1 fc in,
Dludustrial/Comnicrcial DResidential Water St1pPiy(sknrrd) AO'GROUT .. _. :.. ... - .. _ .. . _
FROM 70 •,LITERrAL • EMPLACEMENT arEnion&AMOUAT
El hit9ttti0I1 • - rt. h.
Non-tVater Supply Well:
Mrinitoring . . Dll 6M ecoacry • R' f--
Injection Well: it. ft: .
CDArquifcrRecharge C.IGmntidnatctRcilicdiatian E9SANDiGRAVELPACK('rt'applksbtel: - .
-FROM '10 I-MATKRW I, KatMI.AC:MEM'millionpAgtti(cLStortgc am!Rccovcty l7Salinity WU—le , 33 ' R; 45 ft. Sand #2
17Agnifcr Test f Stot nwatcr lhtrinage-
ClExRctiinicnlpl Technotog ❑Srihsidem c.Conitol
-20:DR(L➢:>.IRG'LOG faitach:nddittonat sKeisif ucccssurvr
DGeodiennal(Closed loop). []Tracer FROM. TO nfiSCRIPTIOS Rohr.linnrnociu4'rnctllyhc:rain vc:ck.I
DGeotlterieal Camino/Cooling Return) DOther(e?plaiu under 121 Retuail;s) .0 -ft. 45 -ft, sand stone
ft. it.•
4:Date Wetl(s)Coniplctcdt 1-3-24 .'\Nell mg TMW-1 ' rL rt. •
•
Sa.Well[Acatimi ,rt. ft. €� "'.- 11„ i.' .§,,^'-'i •
n. ;ft. JAly Lt,
•Facility,OietrrNamo FacpityIDk(ifapplicable). f. .ft.
- � {4
710 Piedmont Triad West Drive , Mount Airy, NC, 27030 11. It, •••:• , i :-,,�11;i'i
Plq sical dddress 'IL-REMARK.'City,and Zip G+r4�r %-,— ,
.ti
Surry • temporary well . •
[wanly I?an;c1 Idcrgi['testlon No,(PIN) 1.
Bli,i.:rtitudc'aliul Q.onbrittldeIn.tieFrceslminbtcs/seennds nr decitnid degrees: .2,,,Q;citif'tcatirrti: •
preen nett,one latilong is sri{iteleni) .
. N W '�; ------- _--� 1'/8/2024
•
. Signalirc'of '>,s�:.rz'a'c . Data
6.Is(ar)the•well(s): DPennanent •or 44Temporary G �S ayin�• -fa ��-7 + .
try signu,g{h&fnifi:. ...:a+fy:i.....:.. ..�,q �•rs r.:e:,!twtutructed ir-mrorrimroe
with'15MLNCtCO2C-"� -?r; 'it;.;;;dC;O2OQWellCnnstroctionSrarutnrdsandrlctra
7.11s this a'rcpairtuau t.iatinl;well; Elito or iiiNo eap'eof Oil!r<ronlhrlsihetapmrldrd to.iiifwllocnem,
if rhis-&o repair,fill au krvnn well iararrtarcriutrbrformnation rrul explain the moire of the
rrrr:irurrdrrir21 remarks Sircticri-arcn the hack of Mix farm. ;23.Site dia rant-oradditionalwelldetails:
YOu may asp.*bank of this page to'provide additional Well site details or well
8.Number of*ells constructed: 1 •consituetiort detai s.'You may also attach additional pages if necessary.
For nolripie lr eve on or r o Neater Srpple-i&'ei&ONLY with the saute rorrsiruEtlorr,you coo I
submit one Prim.. J(•1IIM11 TA 1,INSTCTCTIONS ,
t
9,Total Well depth below Land surface: 45 (ft.) 24a. For Alt Wells: Submit this form within 30 days:of completion of well
Foi•tnntrlplviccifsliPfdiiicyrlasifdOii'trnrfrearnpte.3@a(M'and 3c-rtdlltl .•consttlrctiontolltctoltowing; '
10.Static water level below-top of casing,: (([,} Uii'isirin of Water Resou'rcs,.Infnrmati(in Pruecssing Unit,
if Inner lineal is abiwe razing;use"+" 1617 h[iti[Ser i hen Center,Raleigh,NC 27699-1617
EL Borehole diameter.6 - (in.) tab.Fair jijectigrt tsl)gONLY: in addition to sending the fora to the address in
2-la above. also'subunit a copy of this;form within 30 days-of completion of null
12.-Well cotiserttction niethodc Air . cotrsltoctiou to tiie.followbig. 1
{ic:auger.rotaq,table:direct gDslt.'cp.) Division Of Water Resources,UtrdergrOund Ittjecalon.Control Program,.
FOR WATER SUPPLY WELLS'ONLY: - 1636 Mail Service Ceri ter.Raleigh,NC 21699,1636_
13;a Yiclil(gpm) lie.For Wafer SnpNy St'tnjectton WA:Methodbf test:
Also submit one copy of this form;Within 30 day's.ofc0mpletion of
13h.Disinfection type: Amount:. well constmctinn to the-county hcalthldcpartment of the county wltem•
. constructed.
Fern GW-t North Carolina 0. cnnxnr.of Envinnui,ra-and Natural Resources—Divistoo of W:uer Rtsotsces Revised August 290