GW1--01429_Well Construction - GW1_20240301

i
WELL CONSTRUCTION RECORD
For infernal ilsc ONLS':
This fenn ens b:used for single or multiple wells
I.Well Contractor hlforntation: . ,
'.II:WATER ZONES -
John Eisenman FROM TO DESCRIptioN: •
Well ConttaaaorNanw R.. ft. I I
• ft. It.
4439 i
NC Well ComfaclarCCIIIII alioti Nwiiict AS:OUTER CASING(for-atutil-casediieils)OREI R(ltan ltlenbk4.
FROM TO DIAMETER. THICKNESS MATERIAL. -
•
SAEDACCO ft. M.,
Conpruty Name _t6.'INNER CASING.OR'TUBING(geothermal dosed-loop).:•_ '
• FROM 4 TO• DIAMETER THICKNESS MATERIAL
2,Wclt.Construct€on Permit#: 0 R, 25 ft. 2 ''ha. "SCa-40 PVC '
.1.ht all rpplicnble well permits(ix.County.Saoir•.Varinure.fie dcii,rru'.) I,
ft,• ft,
3.Wdt[Jsc(checks ell use): t7.SCREEN
—. _ FROM TO DIAMF.TRR SLOT SIZE 1111CKNIsS MATRIUM.
Water Supply Well:
i7Agti;cltlttlrat CJMunicipal/Public 25 R. 35 ft. 2 in :030 SCH-40 PVC .
DGeotheitnal(Heatingltooliug Supply} DResidential Water Supply(single) rt. ft. in.
Diodustiial/Conuliercial IJResidentialWaterSuppi)(skated) FROM•. . TO MATERIAL EMPLACEMENT MEIt1OD.4.LMOWT
❑frtifation . 0 ' .rt. 20 ft. Portland ; pump
Non-WaterSuliplty Well.
tt.. rt. ,
*Monitoring ORecovetY- .. -
Injed(on-AYell ft'" (a . . .
0Agttifcrl;cchargc CDGroundi atcr Rcatcdiation - <19.'SANDIGRAV1!LPACK Or aigtlicablel'. ' -'. - '- --
FROM " TO" MATNRta1. • EMPLACEMENT METHOD
DAgiutfcrStorage and Rccovety DSalinity Barrio 23 ft. 35 ft. Sand ' #2
❑AgtiifcrTest ❑Stora:water tiralnage• .
ft. ft.: •
• ❑ESperimcnlal Technology' ❑Subsidcncc Caniml- ' - . ' .'. " - .' ' . . •
2n:DRILLING'LOG(nitaeh-ndtntionnl!Ili eel s if nceessnrvi
DGcwthen11a1(Closed Loop) ❑Tracer - FROM- TO DESCRIPTION(tnbr.haul l wir'nrek 0ter.ctain Fire,dr y
iJ eotitetlual(FIeating/Cnolina Retum) tOther(explain under tt2l Remarks) 0 . :rt. 35 ft, sand
ft. ft.
4.Date Well(s)Completed: 1-23-24 • Well IDtf P-7 .iL ft �F_ -- h�, / "
5a.Well Location: ft. ft.. 4 1 ice. L.1 '�"�" ,
Sampson County Landfill ft. - , , ft. MAR p d 1_2_02�
•
FacBByMieserNnac . Facility IDA(ilapplicable) ft.' ft, . IYUiIl. .
I
7434.Roseboro Hwy,.Roseboro, NC, 28382 R, ft, iil#Oi ti:e3:(:it Yr.^•SIN.:'?a V7p
Plrysicnl Address,City.and Zip• '21:IIElim c's e' -
sampson' . " bentonite seal from 20-23ft
flintily Vareel Idni Ctcattnn No,(PIN} '
'
Sb.Latitude'and t cingitude in dcgrees/minutci/secOnds or decimal degrees: 72.Certification:
(Osten field,or2,lal,1ong is suff'leknl}
N YY - . — 1/28/2024
r _ ,..
Sigiuuacaf"r2::•a �i,ari;: _ Date
6.is.(ari)the n•cll(S): ZiPerinanent or fTemporan - „.r .- rs-r.;i
Hp sigrab,;rho toms r-.r: .i4,!t' ux:,.cr.l�r.,r s r..e:r1 conrtrnc-rrd irr mrorrlenoe
iratrl 15A NCAC 02C.+A. :.-4-t;..Ore.u2C.02Oil 14a11 Cnnurirtton Sraidiards and rlxutr
7.Ls this a repair to an existing well: DYer or KIND iviiyofMir record has beal'inn rirltd tulle'urn mown
If rhtsir a,wain frll ear ksdnvrWeil carumrcfon hrforrnoriorr and eiplaln tSr Harare of the
repair eV irourrdt-.ietaiae or on dm back of rho'form. 23.Site diagram or additional well detatiis:
You may use the back of this page to preside additional well site details or well
S.Number of wells constricted: 1 cot:sanction details. You May also attacttadditianat pages if necessary.
For multiple lafecrinn or norm-wawr tuppk wells ONLY midi the sonde carrstructlon,you Con -
snfrmirnneform. SUDl1i1TTAI.iNSTLJCTiONS ,
9.Total well depth below Lind surface: 35 - (ta.) 21u. For Ail Wells: Submit this form within 30-days of"contptdion of well
For msltlpk it•efls list all dcprhi ifdifferent(ample-I@ 200'owl 20!(k1) tonstnrction to the following:
10.Static water level below top of easing: na (ft-) Ditisliun of Water Resources,Infornwtian Processing Unit,
If n>uler Lewis above meal?,up:"+'• 1617 Mail Service Center,ter,Raleigh,NC 276994617 '
It.Dorehote diamctcr.8.25" (in) 24b.For i eiectton Wells ONLY: in addition to sending the form to the address in
24a above.also.submit a copy of this faint within 30 days of completion.of well
12.Weil construction'method:USA cotislmetion to the following:'
(t.c.auger.rolag•,cable direct pink,etc.}- • .'Division of of Water Resources;Underground Injection-Control Program,
•FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sers'ke Center.Raleigh,NC 27699.1636
13 t Yield( t1n) - Method of test; 24c.For Water Sanely&Injection(Welts:
Also"submit one copy of this ferns Within 30 days of eoutplelton of
13h.Disinfection type: Amount: art!construction to the county health!depanment of the connty"w'hcto
constructed.
Forth GRr-I North Carolina I).parlmcru of Eneirouust tin and Natural Itomurcet-Division of Maier Ficsouran Revised August NIA
I