GW1--01432_Well Construction - GW1_20240301

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. 3.AS
WELL CONSTRUCTION RECORD \A Fat tticnwl Usc ONLY:.-
1, •
Tilts form con be used for single on ntultipk weds
L Wdl Contractor Information: I
At%VAt1ER ZONES I. '
John Eisenman FROM fl ,, D6_SCRIPtION
-Well ContraclorNoma ft, it.
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4439 ft. f• t. I,
NCWdICantmcfarCcniftcalionNrmiJer AS.'0I1TERCASING'(form�tliavicdiiclls)'OR�LINER(if-af iieltdkF
FROM TO DtAMETF.R : THICKNESS 'LtTERtA1. •
S1IEDACCO II. ft. hi'.
CottrpanyNoatc • - _46_INNER CASING ORTIIBIN(;tgcotbermaldased4otpl'
-FROM TO DIAMETER ,THICKNESS )IATERGL
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2.Well Construction Penult#: 0 'ft. 20 ft. 2 Irk SCH-40 'PVC
lift al acpalieu!le%-.41 permits fi:r.County.Stoic.Variance.Il}re beet etc,.) f, ft. in.
3.Well ibsc(eked:well use): t7:sCRF1 N
Water Supply Will'. FROM , TO . '-DIAMETER sr,OTSIyi: TIItcK1IFSS. MATERiAL
ClAgricultittal CIMumicipaliPublic 20 ft. 30 ft, 2 In .010 SCH-40 PVC
. ®Geothermal catin ooli Supply) ®Residential Water Supply(silt(single)
ft' ft. in.
(H &� ►tg g
b ) tR GROUT.:- . •
®LidustriahConmtcrcial DResidentialWaterStpPly(sttd 'FROM TO nLATERu1. E\P[ACE\I}VThEnOD 3A\O[NT
❑lttipntion . . 0 ft. 15 -O. Portland pump
N®nWntcrSupply Well:;
ft,. ft. ,
®Monitoring . .- . pRecovrlY . . . .
Injectlon.Well: • ft.. ft. . .
GIAquiferRecharge DCJroundrlatcr Rctrtcdiation• . }19:SANDIGRAVEL-PACK(if applicable) - - - _ -. -- .
FROST 10' •' MATERIAL H11PI.tCt:HFNT MI311011
i]Agnifer Storage and Recovery °Salinity Barrio' 18 ft.. 30 ft, Sand #2 -
. OAgnifcrTest OStor matcrDrainage*
ft. ft. .
ORyrerintcntad Technolo y °Subsidence Control - - -
-i2az DRILLiNG'LOG(nliach additional sheet lr itcccssar't
• OGeothemtal(Closed Loop) - DTrdcer .FROM TO DESCRIPTION fmbr,Itaninca,,tulr'ntckn_tx.nraia+Ste.cic t '
OGeodteimal(l-IeatiogtCooling Return) dottier(explain under#21 Reittalks) 0 rt 25 ri sand
25' ft. 30 ft, clay
4.Date FVcll(s)Completed: 1-23-24 Well IDMP-5 - .
Sat,Well larcotinn: :•.,
fL r4 i fi ‘I...k..,L::ti: V t.
Sampson County Landfill f4 ft •
A A^,> > y i a
Factiity,+0iso rNantc Facility ION(if applicable') R ft . . ..1Y1#1(���2
' 7434 Roseboro Hwy,.Roseboro, NC, 28382 ' . . . ft. ft. In orG".a i£i1 ate. w0a:3 UIU
PlrysicniAifdixss.Catty'_and Zip' ;2 ti RutIARKS
Sampson • bentonite seal from 15-18ft
Cuuob' Parcel ldcnlificalion No,(PIN) . ,
• $h.J<aiitiide Arid longitude in dega'ceslminutestsecrnds Or decimal degrees: .22.Ccrtifcrnt10n:
Olsen Acid,oaf!Ivllou Is strfiit:l:nl)
A Wes_-- ! _----' ' 1/28/2024
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Sigmtum � ��if.,����:e�:�-;- _' bale
6,Is.(.ire)the tit•eli(s) XIPenmutent or °Temporary By,tsnu,g this fot,65-ul6 if.to u xS,c' i"11. ztin.rm;ered Lr nrearrlioux
with 15A NCAC 02C.'x '•--7'1 Fn:.nt.,':.'C.0200 PWJ Comm-action Standards and Ilsot a
7.Is this a repair tit an existing well: DYes or l9Nu copy ofthir word has[teen provided to gm 1ir11 awn,
Jfthls'is a iepalr;fill onkroit'nwell coaonw,ion hrforrnaiion and explaln'rho ware tithe- -
rrpairwrdrr d21 irnuark Sreaitm or tin the beak of this form. 23.Radiogram or additioilul well details: ' •
You may use the back of this page'M.provide additional well site details or welt
8.Number of wells constructed: 1 - ' - cotisttuctioa details. You May also atlas lfadditionat pages if necessary. •
For'nal:Ole Infeellon or notwrmer a ppli•welts ONLY with the same consfruetion,you Call
sapnit'one font. SULthi1TTAL iNS')UCTiONS i
9.Total well depth below laud surface: 30 ((p,) 24a.-For All Wells: Submit this form within 30 days of completion of well
For tmnitlplc'•etis list all depths ifdifti rou(exaatpk-3@700'arul.2@dtkl) ' • contitmction to the following; I.
10.Static water level below top of casing na .(110 fh•isiuu of Water Resources.Information Frueessing Unit,
If water kw!is above casing,arc'"+" - t611 Mail Service C i ter,Raleigh;NC 27699-1617
11.Burcholydiametcr.8.25" - . (in.) 24b.For Iliisction Wells ONLY: in addition to sending the font[to the addressin
24a above.also submit a copy of this.fury within 30 day's of.caupletion of well
12.Well constittctian'method!HSA - totisttuct1on to the following: r
(Le.sager.raut•,cable,direct pasts etc.}
'Division of Water Resources,Underground Itjection.Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Serelee'Cei'nter.Raleigh,NC 27699-1636
224e.For Water Suppi
13a Yield[g{im) Method of test: _ _ 4:lnjection'Wclls:
Also subtitit one copy of this fOini Within 30.days of Completion of
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131i.Disinfection type: • Amount: well constntction to the county health department of the.counh'.whom
constructed.
Farm GW-t North Carolina 1A:patinient of Environment slat islautnal Resources-Division of Water Rcantrots Revised August U13