GW1--04573_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD Pef(menial Use ONLY:
This form can be,tscd for singk or midnipk wells
1•Well Contractor Information:
II.WATER EONS
John Eisenman FROM t0 DESCRIPTION
Wc11 Contractor tiank R. ft.
4439 It. ft.
NC Well C01111;l.l•n CcnificaiMn Number IS.OUTER CASING(for RwMi-eased wens)OR LINER(Y batik
PROM TO DIANrtrN tnlChxWNs ( MVTFRIkI
SAEDACCO n. (I. ta.
(•ingran, r..,-;1. MANNER CAbINGORTVIIINGIwYermilStwe44unf)
FROM - TO , DIAMETER , TRICK]WNN Mtn-UkL
2.Well('nnsttuetinn Permit N: 0 R. 5 ft, 2 te, SCH-40 PVC
/Jul all applicable well permits ice.County.State.Variance,Injection we! R.
3.Well t"se(cheek well owl: 17.!)CRESN
Water Supply.Well: now to DIAMETER s1At3171 tnu N5is. NSteeim,
LIAgrwultural DMunkipal'Pubhc 5 ft. 20 ft. 2 HT .010 SCH-40 . PVC
CiCeothennal tHeatinKooling Supply) DResidential Water Supply(single) h. ft. iL I
i i ItrdustriaUComnicreial DResidentwl Water Supply(shared) st " TO MATERIAL EMPLACEMENT METROD A AMOUNT
❑Imgetton 0 R. 3 ft. Portland Pour
NoR•Watcr Supply Well: - ft.
NMonitonng ❑Rccotcn _
Injection Well: n. ft.
❑Aquifer Recharge ❑Groundwater Remediation ' 1'r.NAAn r.R%S I L t'i(h NIagdkabiel
�ilNi\i WI, %I 01.11111. YMPI.s(VMEVt M17RMI
❑Aquifer Stomgc and Recovery ❑Salinity Barrier 4 n 20 fi. sand 82
❑Aquifer Test ❑Storrmtatcr Drainage ft ft,
❑E•penmcnral Ttxhnologt ❑Subsidence Control
re.DRILLING LOG(attach rdtliwu.gi•heel,it,SetewI.I
❑Geothermal(Closed Loopt ❑Tracer 'MOM to ; M-c fart ln\,.tiler.Ltrdnrw,reli'nwiro pr.;ranVeer,Oil l
❑Georheal(Heating'(ooling Reim, ❑(Alter(explain under k21 Retnarksi f 0 n. 20 n. sand
tm
h. n.
4.Date WARMCompleted: 6-28-24 Will Ina MW-33 n. n E``a•..!.. -- •• .
Se.Well Location: ft. ft. JUL 3 ' eU24
Hamilton Beach rt. n.
FaclitOancrNanrc Faclil tDN(if applicable) 0:;;x:.• A I`"" �
ft. Cl, If,.
261 Yadkin Rd., Southern Pines, NC, 28387 n _ ft.
Pln steal Address,Cin.and Zip 21.RimARICS --
Moore f bentonite seal from 3-4'
(ouM) Parcel Idc.r1i1ra11on Pie I PIN 1
Sb.Latitude and larngitutk in dcgrecslminutcslsreonds or decimal degrees: ,2.(.erotic aim:
Weil field.nee lei lm>g is sidle:teial
N W .*''. �s
7/2/2024
!�' --
Siamese of . .c Cooti.• Date
6.Islardthewclltsl: XPemmnent or ❑Tempertlry By signing this fo„i' rJ ih :.':x1 a1:or«3.:�,
ts c rr�
twarmit•eel in accordance
with 114 NC4C 02C l.-e•,,.Y.•:r..i ,..1C.0200 Well Cawaftwcrlar Stax,lard..'sf that a
7.Ix this a repair to an existing well: ❑Ytes or END e.>,,v of AHi,reeard ha..been provided ra the twN owner.
If fins as o repair,fill our broma well garcon non nwfornawiim awl explain the no rare of the
repair under 121 remarks nrticne or on the bark of mix form. 23.Site diagram or additional well details:
You may use the back of this page to trroside additional well site derails or well
8.Number of welly constructed: 1 construction details. You inay also attach additional pages if necessary.
For milreple inleeo•:.. •,,ti.ot.0 r ruppft u,•Ih ONLY with the sameconsenteaae.sow ism
Ashton one fc•nr SUBMITTAL INSTUCTIONS
9.Taal well depth belint land surface: 20 (R,1 21a. For AU Wells: Submit this Pointe within lu days of completion of well
For nrwltrpir wells nut all i ... ,'•i,r;,...,v ir•rampfr to'OO and:it WO consinictlon to the foUoeint;
II.Static water lesel below top of casing: (ILI Division of Water Resources,Information Processing 1 nit,
If miler le,rl n admen i Jatoc a,e • 1617 Mail Service Cuter.Raleigh,NC 27699-1617
11.Borehole diameter:8.25" tic) 2•lb.for Inketion Welk ONLY: In addition to sending the form to the address in
24aabase. also submit a coin of this form within ?u days of completion of well
12.Nell construction method:HSA colulnfction to the following.
(1 e.anger.rotas.cable.direct push ere.t
Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen ice Center.Raleigh.NC 276'fr9-1636
13a 1'iiid IElrmt Method dhst 24e.For Water Swppls A.Injection Wells:
Also submit one copy of this fotnt within to days of completion of
13b.Disinfection ty lie: Amount: well cons:m moon to the county health dcpanmcnt of the county where
constructed
Form GW-1 Nbnh Carolina D:pMte:1u of Eta tiotu era aid Natural Resources• Dr.151011 of W ale,Resovea Res riot August 101 I