GW1--01427_Well Construction - GW1_20240301

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WELL CONSTRUC'I'[ON-RECORD
For bee Mal Use ONLY;
This Conn car tic used for single Or tnultiptc wells . •
1.Well Contractor Information:
• allI UTER ZON dS - .
John-Eisenman . Itn031 TO torsettIPtioN
Welt ContmoorName ft • t A, I
4439 ft. ft, i
NC Well CaruracldrCcnificnlion NwiiJer • 3.'INI•CER CASING(foe maul-casettnclls)OR-LINER(inn tl able):
PROM Ili ' DIAMETER. THICKNESS MATE.RIAt.
SAEDACCO ft.,• ft. ;hi,
Company Nantc 16.INNER CASING OR TUBING(geothermal closed-loop)
.FROM TO DIAMETER - THICKNESS MATERIAL -_
0 'R. 10 • ft, 2 1rh� SCH-40 ' PVC
2.Well Construction['tilRltii ft; i'
fit all cprlicable weft penrrih,(Cr.County.Sum;Voriarree.Ileeb 4 era) .R ft 1.is
3.Welt use(chick wdl use): 17.SCRCEN
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Water Supply.Well: - &twit.• . To .•DtAatEll:K SLOTSIFE Ill ICKdMOT 1 MATttR1A1,
❑Agticultutal oMunicipal/Pltblic 10 R. 20 ft 2 in .010 SCH-40 PVC
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1Geothefnlal(Hcatingt'Cooling Supply) ®Residential Water Supply(single) It• ft. in,
Elhiduslrial/Conmlcrcial ©Residential Water Supply(shared) . r:1'I GROfff
FROST- TO .MATERIAL EatPIACENIEVT METHOD&AMOUNT'
❑Ittipation 0 ft. 5 ft. Portland . pump
Non-Water Supply Well:. R .
lMonitnring ORccos•cty .. .
InJecl(ola Weit: ft. ft. .
C7A8uiferRecharge IDOtoundnatcrReniediation 49 SAND!GRAVELPACKfiftytpllcabte)-_ . - ..
warm su' MATERIAL F lPi„%CEMENTMt:TIIOn '
DAgttifer Storage and Recovcty IJSalinity Harrier 8 ft. 20 ft, Sand , #2
❑Aquifer Test DSlornmatcrDrainage ft. ft.
• DEtiperinicnial Technology ❑Subsidence Control• . . . -
2D;DRILLING LOG7aff wli nddilionittstiee&If nceeicnr 1
❑Geottetnal(Closed Loop) ❑Tracer, .e•ROM TO DESCRIPTION(eobr.bantnes+,mn'nKk lrtrt.rrNu hire.del .
❑Geodiennal(Heating/Cooling Return) ❑Other( plain under 1121 Retlarks) 0 :ft. 15 . ft, sand -
. 15 ft. 20 ft, clay -
4.Date Well(s)Completed: 1-23-24' Well m#P-4 ft. ft.
54.Wdl Locations ,7
Sampson County Landfill 'ft, ft
Facility/Onto-Nam Facility IDk tifapplienble) - • - 1 • M :a-9- •:-
R, ft.
7434 Roseboro Hwy,.Roseboro, NC, 28382 n ft:•. Irtftii d"s+fcen�7•.f>,, ;�p -.3 i 1
P16sienlA4dicss.City.andZip' qt.REMARKS - CieJC1i r3Oa
Sampson bentonite seal 5-8ft
Cgauty Parcel Idcritiltcauon No,(PIN) :, '
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Sb.laltitude Mild Longitude in degrees/minutcs/scconds nr decimal degt'ces: 22,CcttltieaHon:
Orwell field,one laltlotx;is sufficient) • • -
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�V = i ;1 1/28/2024
Sidmuu of x i:?c ri rt17,,ha: : -_" . . ----. Date
6.Is(are)the well(s):.2aPerinauent .or DTcmporat `/ j '4. ;iA,r:. :.`s '"Ji--re I ru„Yrnr�fert It,arrorrlanc'Br signore Mir or,r.. 9 t.::rl
irith fM NC,tC 02C.' ,,.%,•;`r Ti'rt,:�:r2c.0200 Rio!Constnicrtatr Smrxfards and Ow
7.Is this a repair to nn eriiting Well: i7Yes or E)No 'espy oithir ri'ord has in en proridri ta'hr tt'rl owner,
If{his'in o bilk*:fill oar r,`OWn..well coru-truriton inforrrurrirnt and aiptabr(it'nature oldie
repair mafcr 021 remarkrarcriun or an the bat of this form. - 23.Site diagram or additional well'details:
You may use the back of this page to provide additional well site details or.welt
S.Number of wells constructed: 1 • • coltslillctloil details, You May also attach additional pages if necessary.
For mairiple hr/eerlon or urxt-never suppir•wear ONLY Writ the same conatradion,you eon
salmi-roue form. SUBMITTALINSTCTCTIONS '-
9.Total well depth below land surface; 20 (ft.) 24a.Fur All Wells: Submit this form within 30 days of•completion of well
For multiple'welts list all depths if rf4,#iyou(example-3@2047 tout 2(3,1430) - constRiction to the following: i 1
10.Static water level below top of casing:na • A) l)Ivisiun of Water Resources,Information Processing Unit,
If nuiet ktd Is above auto.use"+" 1617 Mail Service tilt-Cr,Raleigh,NC 27699-1617
11;Borehole diameter.8.25" (in.) 21b.For'[tijcctirtn Wells ONLY: in addition to sending the form to the address in
24a above,also submit a copy of this fonu within 30 days of completion of well
12.Well coustrllctiou'nlethod:HSA constmctton to the following:
(Lc.auger rolaty,cable direct push.etc.) 'Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center.Raleigh,NC 27699-I636
13 r Yield(gpm) Method test: 23e.-Fm'-Watcr Supply&InjectionlI SVctls:
Also'submit one copy of this forth within 30 days ofcotuplelioaof
13h.Disinfection type: • Amount: cacti construction to the county health department of the county.where
- constnicted. .
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Penn GW-t Noah Carolina Department of Enciroiunait and Natural Resources-Division of Water Rearm Revised August'tol3
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