GW1--03618_Well Construction - GW1_20240613

• WELL CONSTRUCTION RECORD For l.ernal Use ONLY:
The form can b used fall single or multiple reds
1.Well Contractor Information:
11/;WATER ZONES
John Eisenman IROM to ar_WRIPTIN
,Wc11('ortraclor Namc ft. R.
4439 ft. ft.
NC Well Contractor Certification Number MI.OUTER CASING(for ms (-cased well.)OR LINER fit likable)
FROM TO D1%MFTFR —1 THR'ANFSS I MATFRPil
SAEDACCO fl. ft. in.
('cizi un Name (NNE R CASING OR TURING aniernial clawed-Lwp)
al - _ TO DNstiTFR THI('A\Esi M%TTRf1I. 1
2,WdI Construction Permit if: 0 R. 13 ft. 4 6.- SCH40 PVC
Liu all,ipplicahlc well permits ii c.County.Saar.fitriurne frl'd00rt.a.l — - '
53 R• 58 n• 4 ln- SCH40 PVC
3.Wdi toe(check well use): 17.SCREEN
Water Supply Well: Front TO DUMW'rFR SIMs11•T IOUANr:5X Net s flit!LI.
CJAgficuhtiral ❑MtmicipalLPablic 13 ft. 53 A. 4 in. 010 SCH40 PVC
OGeothennal(Heatingcooling Supply► OResidential Water Supply(single! r R. h. is
I"I I dustrial/Commercial OResidentcd Water Supply(spited 1 10
FROM vrt
TO MATERIAL IL111MACEMENT METRO°t AMOUNT
❑Imgation 0 ft. 10 n. Portland Pour
Nor-Water Supply Well:
R. ft.
❑Monitonng WRecosct)
iujectior Well: rt. It.
0 Aquifer Recharge °Groundwater Reniediation r,.,%ND(.1211 I 1 r It h id'a,/Mtsilt)
►RUV _ ,�:� _ 'IciI HI SI RMIM.S('FMINT MrTHOO
IiAquifcr Storagc and Rcc(nen ❑Salitlit) Hamer 11 h. 58 r. Sand #2
El Aquifer Test ❑SIonmsitcr Drainage •
n. I u.
❑Expenmcntal Technology ❑Snhsidcmcc('omml
10.DRILLING LOG Iattach additional iMes•N if aece•san 1
OGeotiirmat IClusedLoupi ❑Tracer rnoM ro DF.cRlrtunN1,u6r,warder..,,.,it,w,l.lope.arau,4e,ar.t
❑Gcoihemial illeatius'C'uolnig Renato ❑Other leNplam under a21 Remarks, A. n'
—
ft. it.
4.Date Well(s)Completed: 5-3-24 Wdl ipmR-27
ft. ft. r . ` 1�
Sa.Well Location: h. n. '' r `�'
GE ft rt. JUN 1 3 2024
Facility.Oo rerN,,a: Tacit'''. ink.(if.,p,l, aHl, - V._• .
R. it.
1223 Fairgrove Church Road SE , Hickory, NC, 28602 R. I �II. ,rJre^'4, r cC.•.M--r.g Uwe
D(trC4 3lr4i
1.,-"I \ideas.Cm.and Zip 2L REMARKS
Catawba bentonite seal from 8'-11'
t.nud,._.. _ Parcel Identification No.IPINI
5h.Latitude and Longitude in degrecsiminutrw.ascennds or decimal degrees: 22.(*retitle • r:
01 wilt lidd one tar lntn P.stdlkianll
N W 5/12/2024
Signanue of„r::,,.. : :Ill i;.,�.,avi;C_ Date
f.
6 is tan)the well(s): �Permanem ur ]Temporary ` �E •,'; fir rea.y+
Bs signo,,q dal fw K •?�•,iF 1 .�:».s.,t.:r:rl txrartnterrd in urronitannr
warn I SA NCAC 02C.';,--..�-.7:.:.'.i t. ,:..'C 020n Well Conortw non Sr.i&l,,Sc and awl o
7.is this a repair to an existing well: °Yes or RN. ropy of this►r+rrmi has helm provided to the well owner.
If this is a repair,fill,set ftnvxw Well(ono?*lwti mlornwarant and explain the abs., of foe
repair aderIII remarks section or on the hark of this form. 23.Site diagram or additional well details:
You may use the back of tiw,paw to provide additional cell site details or well
8.Number of wells cunalr'ucted: 1 construction details. You may also attach additional pages if liecessals.
for malople in*,Non ce m o-wider limp!,writs ONLY n',th the Wait eoea alien.on cam
sabmiu am foam. Lli�l 111.1L.b STUCTIONS
9.Total well depth below ladsrrface 58 (h.) 24a. For :All NSells: Submit this form wohm 10 days of completion of nell
For multiple wells tlsi oil*Mu ifdlrrearlrxaapfr-Tla200'and 2itotorn constnictiontotlicfollowing
10.Static water level below top of casing: (n,) Dis isiirn of Water Resources,Information Processing I nit.
if nuUrr!rid)a ids„r,aswr.we"+- I617 Mail Serice('eater,Raleigh.NC 2 7699-16 17
II.Berelole diameter:12/8 (in.) 24b.Fur[nacelle's Wells ONLY: in addition to sending 11te form to the address in
24aabose. also submit a coin of this form minion '4/ days of completion of well
12.Well coastrrction method: HSA/AIR construction to the folluwtng.
l i e.auger.rota's.cable.direct push etc 1
Division of Water Resources.Underground Injection Control Program.
FOR Vs 1 IT SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699-1636
t3a)'sill wont) Method For V.Ater'uppls .C.Injirtinn Welk:Method of test:—
Also submit one copy of tins folio tsithnt ii dal a of cotnpletton of
131i.Disinfection type: Amount: well constriction to the county health department of the county where
constructed
I ro i(;tit-1 Noah Caroluta U.ipctnntnu of Ens uoiuuiu aid Natural Resources-Dn anon of Water Reolra6 Res iced August 2+t I l