GW1--01472_Well Construction - GW1_20240301

I
WELL CONSTRUCTION RECORD For frontal UseONLY: s '
This form can Imo,used for single or nadtip)e wells
I.Well Contractor Information:
1.I WATERZONES 1 '!
John Eisunman nu)M 1 'iCr OP'SCItoPTIDN
Well Co icior Nance 15 ft. 25 fl.
4439A ft. . 1
NC Well Contractor Coniftwtion Ranter 1SiOUTER'CASiNG•(for:niulii=cauritionsl`OR:LiNER(ifab]licabk):.
FROM I TO DIAMETER TRIMNESS MATERIAL.
SAEDACCO ft. ft. I I hi.
Company Name ^16 INNER CASING'OR-T@131NG'(re+iihci in.it tsedaoiijtl.• '
FROM TO DIAMETER TIiiC&N6.S5 MAiERLAL
2.Well Construction Permit 6: 0 ft. 10 ft, 2 i ' to. SCH-40 PVC
fin all applimble well p.nui s fix.County..1ro'.I'urirrse.h ject C l err.) •ft. ft. in.
3.Welt'Use(check well use): t7;SCREEN . • , 1
�4'aterSupply WeIP' FROM i TO DrAMETtttI SLOT-SW: Tint:KNFtiS I MATERIAL
10 ft. 1 25 ft. 2 in.l, .010 SCH-40 PVC
0Agticuintnd ONIttnicipaliPublie
OGeotitennal(Heating/Cooling Supply) °Residential Water Supply(single) (t. rt. !n,,
fJ h(dustria1iconuaierci aB IJR+sidelltitll Water Supply(shared) .FRO ROUT.TO MATERIAL EMPLACEMENT SrE firOD ASfOnNT
❑hripation 0 ft. 5 ft. Portland Pour
Nan-Water Supply Welt: it, it
®Nlonitoring ❑Rn:o iy • I ,
injection Well: ft. rt. ' I •
°Aquifer Recharge °GroundwaterRcntcdiation :t9.SANfl)GRAVELPACK(ifaitplicahre),.
' FROM TO I MATERCSI. EMPLACEMENT METRO!)
❑Aquifer Storage and Rceovcty ❑Salinity Barrier 8 ft. 25 II, Sand : #2
❑Aquifer Test ❑Stamm;iterDrtinage ft. ft, I
❑Experintcntal Technology ❑Subsidence CoWrol I
-2f::DRILLiNG'LOG(nrtac4:adititioaat sheni if"ticccssnn•1.—
❑Geotltemud(Closed Loup) ❑Tracer FROM I TO DESCRIPTION Cevlar.bnnruc,,,5utUniel lspc.mstn Ste.dt•.I
/sand
❑Gcwtltemtal(HeatiltuCuoline Rennin ❑Other(explain under#21 Retuatts) 0 ft. 25 ft. cla y i
4.Date Well(s)Completed: 1-3-24 Well M# -3R ft. ft. ., c
5a.Well Location: ft. ft. 1.
MAR 0 I 2024
Mullinix Grocery ft. ft.
Facility...Owner Name Facility MN(if appli;ablc} ft. . ft, -----t�Yfofah7.7itien?r.,:,
3079 NC Hwy 109 North, Troy, NC, 27371 ft, ft. •• DWQ;5t4
Physical Addr•ss.City.and Zip 21.REMARKS '
Montgomery 7600 00 07 7264 bentonite seal from 5-8ft
" County Nice]Identification No.(PINi
•
5b.Latitude and Longitude in degi es/minutes/seconds or decimal degrees: 22.Certification: I'
anonlietd.one lavlom it:millicknt) '
35.4145553 N -80.0040240 W '_ ._ 1/8/2024
Sign-auraof'�•, r.,nib.at�s.�— Date
6.Ls(are)the u'ell(s): MlPennauent ur ❑Temlwran rf ,41,1 r!!; r,f.a; :f•-�- itle:•'-�
Br xi.5nn,�:iriY lu3n: , rh•tr ,.rz�. ;..:a::3.urrUatlevf in r~cwrrlrnrr
'tml5it3VC+tCr]„C.• = f d,:C'>i,.1:%a4-,l20Oit'd!Cu,smwrionSrnr.4iords<uidrlvuu
7.is this a tt:pair to an cxisting.welt: Dyes or IQ No eoty.afduc ree..nl;Jaskol lunrul.•d to 3hl•well mower.
!f this is d zcgp:rlr.Jill we(--r:otm wd!(o,n7, trfru hr/aro!in4nl nod,u06u01 rl.r'ware r..10)..
re'sreir wr.irr 011 rroiarki araiaa ar on the base of this funs. 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' cot:stmetion details. You may also;a(tach additional pages if necessary.
For ntnlliple A'ions>n ei oar-a0rer sippis•3refli ONLY with the erne eonstrucfion.Vole c•nr,
suim.irunrPM. StIDMiTTALiNSTUCTiONS r
9.Total welt depth below land surface: 25 (fl.) 2aa. Fur All Wells: Submit this form within 30 days of completion of welt
For mal/ll lr.ed!;'tin rr(1.4inbs if dill-rre,u le:ranhpfc•-t•e':o0'dad 2@ 100') contlnictton to the following
i i.Static water level below top of casing: 15.5 ({I,) Division of Water Routines,Information Processing Unit,
lrnvtmr lre•rl is.rhrn•r(3.1si1.3t4 use'•+" 1617 Mail Stu-rice Center,Raleigh,NC 27699-1617
11.Borehole diameter 6 (in) tab.For Injection Welts ONLY:,in addition to sending tire fount to the address in
24a above. also submit a copy ofIthis font' within 30 days of completion of well
12;Well nurstntetiotl method:Air construction to the folluwine: l
(i.e.sager.Maw.cuhle.direct push cte.I
Division of Water Resources,LJndergroteud Injection Control Pragram,
FOR WATER SUPPLY WELLS ONLY: 16636 Mail Service: ni er.Raleigh.NC 27699-1636
24e.For Water Supply&loin Lion Welts:
13ii,Yield(gpm) Nletbod of test:
Also submit one copy of this Intuit within 30 days of completion of
____R_—_"___�^_ well construction to the county health department of the comity wI re
I3b.Disinfection type: _. Amount:
canstnueted- I.
Font'OW-I Noon Carolina Department of Environment and Ntuurat Resources-Division of Water Raourm Revised Atgust 1n 1 l