GW1--01426_Well Construction - GW1_20240301

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WELL CONSTRUCTION RECORD !
, ^v\ Pgr[utarnolUscON1;Y:
Th6form wnbc used fir singleorniullipkwells ` \(
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1.tiWell-Ctjntractor information:
'aft W tT1?RZONES
' , John Eisenman FROM 10 DESCRIPTION'
Well ConlrsaorName. • 15 ft.. 20 ft. -
ft' ft..
4439
NC Well Cora e1orCcfification Ni niicr •.ES.OUTER CASiNG(cur®tutlikused wills)OR L1NERlll an ileibk)! •
VROAI TO nr,Abtr.TGR.. Iturtirass- �.MATERIAL
•
SAEDACCO - It-- ft.. itl'
Comistnj•.Name .16:INNER CASING OR TUR➢NG(gcotherma1 ctused400 j).
FROM . 10 •DIAMETER. THICKNESS MATERIAL
2,Wclt Consttuelxtia Pciutit . . 0 R. 10 ft; 2 -la scH-40 . • PVC '
l ist onappli le war prmeirs ri o:Counrv:Strr',.Vgriarare..friscriort o:.) • ft., ft.. - r t"`.
3.Welt:lise(check Weil use): ta:SCRLEN -
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WaterSunpty Weil; " -- — FROM. TO . .DtAAti,Tr,R • SLOT SIZE TIIICNNISS. I-MATERIAL . .
DAgacultittal CiMunicipal/Public•
10 R. 25 ft.• 2 ii� 010 SCH-40 PVC
CiGeetlleunat(ieating eopiing Supply)' . ®Residential Water Supply(single) • R. It.: Is. I
Dlndustti�llContotefcial IJResidential Water Suppiy,(sband) oAR(nrr TO ' MATERIAL ' E\rPtACE.\lENT 3IET11OD&AMOUNT
' Elltti€ation • ' " 0 fI. 5' ft Portland Pour
Non-Water SuPplY Well • - •
limonitoting _ ElRecotrty _. • . • �.
Injccllot%We(i:. -- R. . ft: ,
• DA •
quifcr ccliargc - ClOiouridwiticuRentedialioo E{(i
' `t9.SANDrGRAVELPACf applicable)' - . -
`FROM - 10' - • W.TPRIAI. - • itAIPLACru t;it7n0n
PAgnifcrStortge-aed RecoA'ct3' flSalinity 8aiiier 8 R.. 25 ft. Sand #2
ElAquifcrTcst IJStommatcr l)rcinn
ft. 'ft..
. 17Espcdmctitaal Tochnotog. DSabsidcttcc Con col
-2o1 DRILLONG.LOG-(atlictt additional,sheds if nccessarcl
DGeotheuttnl(ClasedLoop) ®]Tracer- . FROM 70 DESCRIPTION toobn6;Wncrrrsog4sicttls pr.t•ssiarire.c.tet
DGeotliennal(H alingJCooline Return) •DOtlter(mtplain under A21 ReuiatEs) 0 :ft. 11 ft, sand stone .
11 It:. 25-. 'ft- rock . : r s.•7.1 r,._
4:Date`�elt(s)Coutplcicd 12-21-23 ..Well1DffMW-4 r 1 if LE•. i
5,.Wcll i nca6fn: .rc. ft.. i. MAR d 1 202..
Eaet7it}'lOiroerNnuec. Faotlit}'1Dk.Cufapplieable) -• tffl(rflfprly:f;':•a_
R. ft. ,;.. po:
4993.Plank,Rd, Norwood, NC, 28128 .R. ft.". - I ,• -
Pli sicalAddressCitg.andZip' 21-R1:1t1ARES_ • .
Stanly 654201492345 bentonite seal from 5-8ft I
County P celldeoliClealOnNo,(PIN) I•
51,l atitade l aril unguaile in degrees lminuteitscconds tir decinoal idcgrccs 22.Ce titicatinu: ,
(itiiell Eat,one i:t(ilo>i Isstrfuti:nl) , .
35.1985912 N -80.1900598 w � � — ` 12/22/2023
SigtAittiiquf ?:w 11�u..e ::;: '
6.Is arel tthewefl s:-:lPerinaitent -or' DTert orary y. ,n/ r"'"ss-r-:,.r!a'p !a
( I () p ^Hpa{gnuig thls.fune., ...way rl.., rrxe..•c.gJt rids-t,.e:rf svarrrucred hregvargpre
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Willi lSat NC1IC UZC•' t 7t r4,I::1L,0200 Ri1lConstrrlcitar Stnixiards and riasaa
7.Is this a repair to an exiatiu,;well: DYev or 19No avprofchic record Iias been provided taatra qrN oi1.7icr,
If floes'is a rs•)wlr:fad!teat.krtoitil well caiutnrctlon Inform:Io l am!ripto!t the tuarare oldie
repair tinder 92lr aris'st litinocanncebarkoftliisform. 23.Site diagram or additional well lctadts: " . -
You nia3 use the back of this page to provide additional well site details.or.tietl
8.11utmbet;of A EIN rnastrncted: 1 eousttuction details, You tuay alga attach additional pages if Iiecessaly.
For'rnaltlple lr;jecilon or wain-hater Sup*trills OISLY with Me sarn_e(onstruction,you extra
subnrironeform. . . . CIIQOfITTAVINSTUCTIONS. i
9.Total well ilcpth hefoy laud surftice: 25 - • (tt_,) 3ia. For All Welk: Submit this form within 30-days of completion of'Well
For nutyplrwrlls list all depttsifdi,()iaent(example-3@200'and.2@I0O construction to thefottossing: i
is
1(I.Static water Level below tap of easliegi 15 ( ,) Division of Water Rcrourecs,Information Processing.Unit,
If wino.lesi1 Is above a!siiag,rue."+" 1617 MailSu•A•icc Center,itaileigh,NC 2769.9 1617
11.Borehotediainctr. 6- - -- '(in.) tab.For tnlecttrrtt-Wets ONLY: In addition to sending the fotut to the address-in
24a above.also.submit a copy of this form within 30 days of completion of well
12.Well canstivation-method:Air Rotary - construction to the following:' i
(Lc:pager.iotwy'cabia.direct;ash,etc:) 'Division of Water Resources,underground Injection Control Program; -
FOR WATiER SUPPLY WELLS ONLY: - 1636 Matt Service Center,Raleigh,NC 27699-1636
f3ai Yield(�trn) Method of test: 2-Le.For Water Supplv_&lnjcctioaWelLs:
Also submit one copy-or this fdmi•ieithin 30,daysof completion of
13h.Dicinfeetinn hmc: Amount• well construction to the county health department of'the.cormty.whetc
constricted.
Faith GW-L Noah Carolina IA aiUne i of prirountsil acid Natural Resources-Divisios of WoIerRr5C®tat Revised August2el3•
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