GW1--04540_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD For Internal Use ONLY-.
Pits form;.;tit he,t';A I- .rn::k or multiple.0 II,
L Well Contractor Information:
la.WATIR ZONES
John Eisenman PROM to INSCRIPTION
Webb('ntartcler Name ft, rt.
4439 rt. n.
NC Well Contractor Cerlificalion Number 11,OUTER CASING Our moni•cased%cash OR LINER lid ap Nesbitt
nom : to j IumrrrR Tntt'KNYNs 1 NAttatIt
SAEDACCO n. ft. 1 ill. lI
Compass Name 14,iNNIR CASING OR TUBING t5Mbers._al dsstd•luop�-
►ROM TO 5LLM[TIN THICKNESS N.A IT WI
2.Well Construction Perish It: 0 R 1. 8 ft. 2 •. SCH-40 PVC
Liu all appli,'able u rut penalty fir.Caseate.Starr.Variaarr.b1 toi etc.!
3.Well I se icheek well user 11 8C71IIN
Water Supply Kcil: FROM TO Dt*%Dtra ninonTgK1cNSSs j MAtxat+t.
I_IAgrwultural ❑MunicipaLPublic 8 R. 23 ft. 2 ins 010 SCH-40 PVC
I(Geothermal IHeating,Cooling Supply) OResidential Water Supply(single) ft. n i`
I I IndustriaUComntercial OResidcnnal Water Supply(Aired) 1t'CWVf
FROM 70 MATERIAL EMPLACEMENT METHOD A AMOUNT
❑Irrigation 0 ft. 3 ft. Portland Pour
Non-Water Soppy Well: n. • —�
XMantonne, ❑Rccaccrr __,
Infection Well: tt. ' ft.
J❑Aquifer Recharge °Groundwater Recdi:u ion I.,.S.AND�(.R t:SLPACKC lit apPRrat e)
ni - -
maOM Ti) mAttltst rm M.i(tMTNT Nf1NOn
0Aquifcr Storage and Recover ❑Salinity Ranier 6 ft. 23 ft. Sand 82
❑Aquifer Test ❑Stommatcr Drainage ft. n
❑Expenmenlal Technology- ❑Subsidence Corlml
ba,DRILLING LOG Isitach additioasl shade if accessary)
❑Geodiennal(Closed LoopI ❑Tracer i room To _ INS(_IurtION i,.,.r,hardsew,wildpK-h!INN.mix a mNt.l
❑Geotlir final(Heating/Cooling Return) ❑Other lexplamm
under
n21 Reatls) 0 ft. 23 ft. sand
ft. n. . ''f r D
6-28-24 MW-31
4.Data Well(st Completed: W'dl IDO ft. n.
5a.Nell Location: ft. ft. JUI- 3 ' 2°24
Hamilton Beach ft. n +,}F
r.irihh(hu a Facility ID
>irNar Nfifapplicabk) 1,s..3:rt= '
R. II. Oth.`::5a...‘,9
261 Yadkin Rd., Southern Pines, NC, 28387 ft. ft.
Phsscam Address.City-and Zip 21.intuits
Moore bentonite seal from 3-6'
('ouWi Parcel td,:ill afactl ion No !PiNi
Sb.Latitude and Longitude in d►'grri w minutcc.'sccnnds nr decimal degrees: 22.('erdficadtia:
Of well skid.one Wow is sdtiekatt
N W' ,--- - 7/2/2024
Signaluic of t^•• •:oitn i i.nie:ci•— -- Dar
I.Is tarsi the willlsl: IDPermanent or 'Irmluiran ,�a c.�t
Bt signing this foinc x a t.:etel emorurrrd in ocean/amt.
with I SA NCAC 02C.'1.,,r-•,-1:4,.('A.iT1C.0200 Well Conatrsrhan Sw.dardi and rho a
1.1s this a repair to an etisti.H well: Lib cy or X'S0 cops of(hit record ha.,brew provided to the mint owner.
if)hia in a reputn.Jill<xu kn<.an I. ,<.ru1nm low infarmpenx,WA/r memo On outran,of rho
repair under 021 remarks grange or am the hark of this farm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of welt corntrrcted: 1 construction details. You may also attach additional pages if necessary.
For.tmsinple inirrn,.n M non-N'Ufer mopplt urlh ONLY wail thin urine cnrrafrhwan4 wma INN
aabutirone forme. SUBMITTAL INSTUCTIONS
9.Total well depth below laud surface. 23 (n.1 24a. Fur All Wells: Submit this form within zU days of completion of well
For mahip$r urit.lilt iea depths ifdtfferent i<aam'pfr- f ZOO'and.''!1 )' construction to the follnwing:
IS.Static water ksel below sop of easing: (ft.t Division of Water Resources,Information Processing I.nit.
If more letrl/.,tho I.•asiax.WA' • 1617 Mail Service(cater,Raleigh,NC'27699-1617
IL Borehole diameter:8.25" 11a.) 24b.For Inieeeloa Wells ONLY: In addition to sending the form to the address in
liaabove. also submit a copy of this form within 10 days of completion of well
12.Well construction niethed:HSA coisiniction to the following
i I c.super.ratan.caste.ditto push.etc I
Division of Water Resources.Underground injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail"ens ice Center.Raleigh.NC 2 7699-1 636
13a Yield(gpm) Method of test: 24c.For Water Suppl A Injection Welk:
Also submit one cops of this futon within to dams of completion of
I3b.Disinfection tope: Amount well constriction to the comity health department of the county is hcrc
constructed
Fenn GW-I Nonb Camino Dcpmlmea of Ens imoosrni and Natural Resources-Donlon of Water Pessaries Re..iscd.August o I?