GW1--01431_Well Construction - GW1_20240301

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WELL CONSTRUCi'ION RECORD Far internal Use ONLY:
This Conoco be used for single or multiple wells'
1.Well Contr ctor Information: ,
t1t\VA11tR ZONFS 1.
John.Eisenman " Imam TO nr ritiPtiou
Well CottractorNaos: - _ ft. ft.
•
4439 ft. ft.
NC Well Contractor Canifmntioti Ninth 'tS.OUTER CASING ffor"muttl-eased•n'ells)OR-LINER(If-tip':neabk)
• [most It-) dtASw1F.R- THICKNESS SIATTIOAt.
•
sAEDAcco ft. ft. ,In.
Company Name 'i6:INNER CASING OR TEEING(pcoiturznal efoscd-Iuxp): ' " `
"FROM To DLLNIETER THICKNESS SIATERIAL
2.Well—Construction Permit#: . - 0 . rt; .10 ft, 2 I''[IL scH-40 PVC
Liu usrpplicuble well permits fire.County.State,Varia.rcr.Infactiort etr J ft;' ft. iht.
3.Welt Use(cbccl:well use): t'k SCREEN ' •
®WaterSupjiir Well: V1to51. TO •dLt1tE,TRR sl,otSt1. T110(N MS i HATuotat, .
17Agricultural CJMunicipal/Pttblic 10 ft. 20 ft. 2 in ;010 SCR-40 PVC
• DGeotliennal(Heating:Cooling Supply) ©Residential Water Supply(singe) ft. io.
171ndustrial/Conmtercial . • ElResidential Water Supply(Aired) ,t9:GitotJT•
FROM TO .1ITATERLIt. ' E\IPLACESn?VT METH— O'D&AA\Iotl1T
Dlttipation . . 0 ft. '4 ft. Portland' pump
•Nou Water Supply Well: • ft. It.
SIMonitoring i]Rceoyety. . •
Injection Well: - ft. ft. ,
El Aquiferfccltargc' Eldroundwatcrllclticdiation ,t9:SANIIIGRAVEL'PACK(if alrpucahteli -.- - -
PROSI TO" 'MATERIAL EMPLACEMENT SIIYoon
❑Aquifer Storage and Rccovety' IDSalinity Barrier 7 R. 20 ft. Sand • #2
❑Aquifer Test ❑Stornmatcr Draina a ft. f[,
❑Ecpetintental Technology ❑Srtbskten c Control •
'20:DRILLING LOG'(attach additional sheets If ncccssnni
LlGaocliennnl(Closed Loop) CJTrdcer" FROM . TO . DESCRIPTION(cobr.I,ordneh,wli'nrrkOO tw.min via de t
IJGeotlteultal(FleadnUCoolina Return) 17011tcr(txplaiit under 421 Rethinks) 0 •ft. 20 iL sand
ft. iL ,
4.Date W.ell(s)Completed: 1-23-24 {Yell meP-9 •
ft. it.
• � � ..
5a.1Yc11 Location: i[. ft.. � �''' �i 1..Nr
Sampson County Landfill rt. ft. MAN "J 1 2_0 t
. Fa ellity,17icrerNmuc Factlin-tt)k(iIapptiaable) -ft. It.
•7434 Roseboro Hwy,.Roseboro, NC, 28382 • R. fA t1t(v1 ri.e4i4.41: r..wci4@4 Vit1
Plrysicnl Address.
City.and Zip FAIFI i IOG
2l.ItEai,lttlCS'
Sampson bentonite seal from 4-7ft
County Patee1 ldetaific,1iipu No,(PIN) '
Sb.l;.thuds and Longitude in degrees/minutes/seconds or dccinull clegr ees: 22.Certification:
(imurll kid,orle l.•tltloug Is Sldiickitl)
N - W - --- 1, -----• 1/28/2024
4.4•• ' Signature of.F � 1..� u: —Oats
6.Is.(are)the wells)] ZlPernraeteut. or 1:Teutporary w a• g�. ,tip.,> ? c�a
Hy sigrtuig alrfr fbrrr.- r o,ul :,;.t MIS t r:e:rl irrarrrttered fir axranluace
with 15ANCACO2C-'x=+�•:13:,;a:nZT fC.021'111WellConstroctfiutStandardsandrlxva
7.Is this a ripair to an imttingwelh ElVes or l No ,n>lirof Mir record has'Iwo pa>rirkdtotl?arirllowner.
If ibis'Is ra reptile:fill oat brawn well tionaructloa lnformrrlmr oral explain the nature of the I
repair'rrinder021 remarks-Icahn;or on the brxk raf 111is form - 23.Sift:diagram or additional.flit details: -
YOu may use the.hack of this page to.provide additional well site details or well
S.Nutuber of wells constructed: 1 • Caustnlctiou details, You may alto attach additional pages if necessary.
For multiple Irtfecilon or not-a-awr supply hells ONLY with Me same eiursrrunton,von eon
sainmirirneform. SUBMITTAL iNSTLTCTIO_NS
I
9.Total well depth bellow land surface: 20 (fe.) 243..For All Wells: Submit this•Torn.within 30 days of completion of well
Far multiple wells list all depths If different(example-3®200'on..2€100)" Conslmctionto the following: 1.
10.Static water level below lop of casing.:na (fr) Division of Water Resources,Information Processing Unit,
Ifutiler level Is allure easing;use^+" . I617 Mail Service Citrr,Rale gh,NC 27699-1617
11.Borehole diameter:8.25" (in.) 2-1h.Far Injection Wells ONLY: lit addition to sending the fern to the address in
24a above,also submit a copy of this foun within 30 days of completion of well
12.Well constiatetion method:HSA. • coustnection to the folloc ing:
(i.e.auger.rotary,cable direct push.etc.)
'Division of Water Resources,Unifier.•ouud Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Censer.Raleigh,NC 276994636
13;r Yield(Apra) • Method of test: 4c.for Water Supply Se Injection�Wells:
• Also submit one copy of this form Within 30 days of completion of
13h.Disinfection type Amount: well construction to the county health department of the.counlv.wham
constricted.
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For n GW-1 Noah Catalina Department of Encirmurriu and Natural Resources-Division of Water R grace Revised Algust20I3
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