HomeMy WebLinkAboutGW1--02810_Well Construction - GW1_20240506 .9(.. '
WELL CONSTRUCTION RECORD \ Fur ltgcr;ril Use ONLY:
This form con be used for single or multiple wells.
• 1.Well C6ntrtctor information:
It WATER ZONIS
John r Eisenman' .. - - ENDS! •• .TO DESCRtPTZRNI -
•
W 11 Cot niclorName, ft.; • ft. I , . •
4439 ft. ft. • I J. -
. • NC WcII ConlracforCcnific_ation Nmiitet • ' 'tS.OUTER CASiNGIfor mutli:tisr iite051 OR LiNER(if an•ilcrhlc):
. _ FROM TO DIAMETER r , THICKNESS. MATERIAL
SAEDACCO • . , f6 ft. lw
Congranj Nome I6:-INNER'CASING OR TUBING igeotlenrralelosed-loniii.' ,
- ",FROSI - TO DLL METER THICKNESS MATERIAL '.
2.Weil ConstructienPeniitt< . • . 0 'ft. 25 ft. ,2" '61. "SCR-40 PVC '
list all applicable well pennks.(i:c.County.Stat¢..Vprinore.lobe cq,efr:l •
rt.. ft.: • .
3.Well Use(checl:well uce): 17.SCRtEN
Water Supply Well: - - --, FROM. .1 TO .DIAMETER SLOT sin THICKNESS MATIhRIAI.
25 It,
Cl tgr(cultlilal t fl lunicipaitP•ublic 1 35 'ft. 2" in: I.010 SCR-40_ PVC _ •
. . . CGeathemtal(Heating(Cooling Supply)" .❑Residential Water Supply'(single). . ft• 2 ill .
i2hidustriaVConmtercial Residential Water Supply'(si>arrd) `t8:GsruT . . . -
FROM - Tq '.AfATERrAL,. . EMPLACEMENTSIETHOD 4AMOnNT
. • ' ❑rrii ation . • • . . 0 ' .ft.. 20 .. ft. Portland' Pour
Nan-Water Supply Well:_ - • rt. ft
' ®Monitories .❑Rccoyery . ' . . .
Infection Welt: . - . . .' R,' ft !
i1AgnifcrRetharge EiGroundiatcrRctncdiation 19 SANDIGRAVELPACKlifapplicable). . . '
FROM ' " I TO ARTERIAL I. - • oMPLACEMENT NI FTHOD •
0Agnifcr.Stel igc and Rccovcg' (]Salinity H irtict 23 R,: 35 ft, Sand ;' $2 •
❑Aq iifer'est . OStomovatcr Drains k. ft.
. - ❑EsTetimar(al Tcchnotogy ItiSnbsidcnee Corr4rol ..
•20.DRtLLING'L0G(attach additional ghcNS if ncccssan•1 '
•
❑tseoiltemtal(ClosedLoop) . ❑Tracer - . .FROST • .TO DESCRIPTION(crobr.NArdnCN,+d)a4ackli'At.ersin Stet.dcl - .
❑Geothermal(Heating+Caolitie Return) ❑Other(explain under A21 Rethinks) fL fi,
ft. . ft ' .
4.Date Well(s)Coutpleted:'4-12-24 Well IDNMW-3 .
5a.Well Location: fL h. 1+. :,...-<;.,�I.-.v. is r.•.t..r •"
• Branson's Auto Service H: 11. ! MAY 6 2024
FactlityAlicn:rNamc .Facility iDk(itapplicable1, _ • , - • ft, fl. • -
• - i
210 E. Main St., Thomasville, .NC, 27360 . . •.R. •" _ft. llrVi?•,-.�+•'• ?7'•1•,..C.I,,:y Jr.);
• • Physical Adds ss City.and•Zf • [:4,`�, 40i,1- . •
. . 0' p 21.REMARKS
Davidson. . . ._20-23' bentonite.seal
Comity . l tsel Idcatif tlen No,(PIN} I• '
. . •5h.1,atifude and Longitude in dcgrevo/minutcsfseconds or decimal tlegiccs: 22,Ccrtificat1on: '
pr.%leilfvelI,on:laillotigit!nrfliclets)
W f-=-! •;"'--— - 4/29/2024. . —
. Sigutureu[:.r::hta: 'f u,L ' _ .Date
• 6.Is fare)the well(s): 30Pennanent. ,or' (Temporary. �'.i Z,ate a� iys >er r�c<�i
My algning(hie fw,n,7^ r Aeafv.,.., +: c:0 h cs j Y.e:r/am.unrcred Jn,aarotwtmtce
• - • nittr 15,t NC tC 02C. _i~.;�13 -,t L.ZiC.020 Well Constrrrrrlar Standards and This e -
• 7.Is this a repair toan existing well: ❑Yes or 11No ropy oftrikrrcordhosbrcn'prmidedi gniurllrnnirr. •
If tbls'Js o rcpalr;fill ore r`noirri itTil corurnrcrina.hrform rinn and explain rift torture of rlia - • - ' .
repairwrder.?l remarks:ireiian fir an this boa.of etas'form. 23.Site diagram or additional well details: .
• • You oink use the hack of this page to..prosiide additional well site,details or.Well
' S.Nundnerof wells constructed: 1 • - - • • cotistnrctiondetails. You may also attach additional pages if necessary- ' • • .
For'ntnlrlplciofecilnn.orntur-irarewsoppli,wits.O,'LYwith thruntie cotrsirueiloa.yournn ' j
' sa&mirone ore.- ' , • - SIIRMITTAL iNSTUCTIONS. 1,.•. . .
9.Total well:depth belan'iand surface: 35 (II) 2.12. Fur All Wells Submit this-fort within 30 dais of:completion of pelt - -
. -Fortnnlrlple icelrlist all drprlu If dljli.rrnt(nrarnpte-3@ 00'and 20l(Kt) constniction to the following: • .i• . - - - " - . •
10.Static water level below top of casing:_ - ((Y,) Division of Water Resources,Information Processing Unit, '.
If wort letiel is above cask:ate"+"" 1617 Mail So-vice Center,Raleig ,NC 2 7 691=16 17 '
•
- -IL Borehole diannicten 8.25" - ''(in.) - • tab.For"Iojeetioit Wells ONLY: in addition to sending the form to the address-in • • - •
24a abate also submit a copy of tliis.foiin within 30 days of completion of welt
12,Well construction Method:ESA . . constmetion to the following: - - -
(i.c:auk c rotary,cable,din ct rink.etc.) . . 'Division of Water Resources,Underground Injection Control Program; . • • '
FOR WATER SUPPLY WELLS ONLY: 1636 hell!Service Center'.Raleigh,NC 276994636
13a add(gpm) 24e.For Water Supply&Injection Wells: - • ,
Method'of test:
Also'submit one copy of this'form within 30 days of completion of -
Ills Disinfection Amount:•
• well constriction to the county health department of the county.wherc•
constructed. I•. '
FoiW-t . • North Carolina Depillmem of Em imiuiriii and NaturalResoi rces-Division of WatcrR_em •ni G Revised A_tgu t2tWs