GW1--04553_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD For!MENU UxMIN:
This remain be used rs r singk or millipk wells \6 \(44
1.Wdl Contractor Information:
14.WA *ONES
John Eisenman PROM 1O WtSCRI►tIIIN
Wc11 Cnrari ror Nall VI. ft,
4439 h. , ft,
NC Well Contractor Ccnifnalk n',unto .OUTER CASING(for muMi-emad ee�Olt LINER iW applkabk)
' 1NOM TO Dt4Mrrrs THNsiNsss MATTNI kl
SAEDACCO h. ft. i sa.
(nnp:un NJtrle le.INNER CASING OR TUBING(Raatlertd cle.ed4wipl_ ,____.
MROM t To DteiMETRR TIIt(A+FS. MATERRL
2.WdI Construction Permit k: 0 ft. 25 ft. 2 Is SCH-40 PVC
Las all applicable aril guano.fir.Countc.Stair.Voriamrr.Itle[tsorl en-.I
-
ft, ft. la.
3.Weil l7se(check well Ose) II.8CREtN -
Water Supply Well: rlOW TO ot+atITtN SLOT 5171 7 n11(1(I+RVS MATItUtAL
LIAgricultural LlMunicipaLPublic 25 ft. 35 ft. 2 is SCH-40 PVC O10
LlXxothenttal(Heating/CoolingSupply) LIResidential Water Supplyh ft. is
Stipp (single)
I IhidustrialiCommercial t7Residential Water Supply(shoed) 1f �
PROM TO MAtrRmAL EMPLACEMENT METHOD A AMOUNT
Dlmgation 0 ft. 20 ft. Portland Pour
Non-Water Supply Well: '
ft. ft.
NMonitonnr; ❑Rccoccry _--4 1
Injection Well: rt. ft.
OAquifer Recharge Cigmnndw'atcr Remedial re n 19.S.c'D±I.RN'EL PACK Of applicable)
FRONT 10 M*TrRL+I. EMPLACEMENT METHOD
ID Aquifer Storage and Recovery ❑Salinitn Barrier 23
23 n. 35 h. Sand #2
❑Aquifer Test ❑Stonmtatcr Drainage -. ft
❑ExpcnmctMal Technology' ❑titthstdcrcc Cwarol N.mitt 11Nr.LOG WY*additional+bcel+if arce++en)
O Geothemurl(Closed Loop i ❑Tracer Hot.'t.I : to DESCRIPTION i tabu.h.rdue,.,"iii'na L hpr.r.O ah,de.l
DGeothemtal(Hcatrog'Coohue Return I Dither(espiain under N21Rciii, ,•., h. h.
' ft. ft.
-
4.Date Well(s)Completed: 6-20-24 N cif IDA MW-7 ` f,— .
;a.Well Location: h ' h . LJ+ Sul I.-,
h, h. 4 r�
Pope's Dry Cleaners rt. h, JUL 3 1. 2024
Faciliq Ads ncr Name Facility mo(if egplicabkl
h ft. 3.... :.1+fit
n 1408 Corporation Parkway, Raleigh, NC, 27604 R. n. 111; •• +••" - .
PMsical Address.Cin.and Zip *21.RI:MARICs
Wake bentonite seal from 20-23ft
('nom. rano is:none:moo No I PIN'1
5b.Latitude and longitude in dcgrccsiminutesh(tcnnds nr decimal degrees: 22.Certificadoa:
(Ifcell tell,on.:I:u,intsg Ia sidI'scscud)
N W � 7/2/2024
g _- - Date
Si obi"aw `.'h:,,.�a i;=-
6.U>leer)the wrlllsl: lO Permanent or Temporary M ri8res ,Ida o,rs •;11461 .i s. :,xsue N. rti ernlrucred to accordance
with I SA NCAC 02C. .r-'7:::;;i4A+.::lC.0200 Well Cdgnwrpar Standards and that u
7.Is this a repair to an existing well: l-es or X No <'.Tr.-of this wort,has been praruled rn die aril owner.
If Ale is a repair,fill trot bloom WW1 I'mom non stone otrot and a+pane rh,'ware 01 the
repair under 121 remarks Archon or on the bath of this form. 23.Site diagram or additional well details:
You may use the back of this page to pm+)de additional well site details or well
8.Number of wells constructed: 1 construction details. You tnay also attach additional pages if trecessan.
For mat)ple infection.o n.e-sot.',orgy*.writs ONLY with the owe cuss aeMnu woe roe,
submit one loan. Si I BM ITTAI.INSTUCTIONS
9.Toed well depth below land surfaces 35 (f1.1 24a. For All Wells: Submit this form %%ohtn 11.1 days of completion of well
For multiple wens list un c1elmbT ifd&$erros s,'.ampre-30200 tusd?@ 1(51) consinrction to the followi rep,'
141.Static water Irsel below by faraday (DJ Diriskin of Water Resources,Information Processing Unit.
If wale,leert,,above.asrsr.ale,.4' 1617 Mail Service('ester,Raleigh.NC 27699-1617
11.Borehole diameter:8.25" (ha.) 2-lb.For(niceties Welb ONLY: In addition to sending the form to die address in
24a:thin e. also submit a copy of this fonts within 30 days of completion of well
12.Well cotatniction method: HSA _ _ construction to the following.
tie.auger.roan,cable.direct push.me.i
Dhision of Water Resource.,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: I6il.NI.ril'.can ice Center.Raleirh,N( 27699-106
13a Yield 11tpm1 Method24c.For V.Ater buppl� .Injection 11'cll.:
of test:
Also submit one copy of this form within io days of completion of
lib.Disinfection type: Aft: — well construction to the counts health department of the countywhere
Constructed
Form GW-I North Catalina fpu(lnrm of Em inrurrrn and Natural Resources-Dn aloe of Water Reorrcm Res wed August 2011