GW1--04574_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD For Internal Use ONLY:
The reran can be used for single or multiple acts
I.Well Contractor Information:
14.WAita ZONES
John Eiseman IntOM To Dra'RtPTtf'
R. ft,
Well(bntrlctta Name
ft. ft.
4439
NC Well Contractor Cell ift alien Number _15.OUTIR CAsfNG(for mahl-sasrd wells)OR LINER l if ap NcaAk)
Elitist TO MtNIFTrR IIIIVKNYSS MATT RIM --n ~
SAEDACCO O. II. i..
Common Name 16.INNER CASING OR TURING ljewrhermal clinei-larp)
rrOM - 10 i0 � -- DIAMETER TF11C'KNT�s MU{-nlyn
2.Wdl Construction Peratto it Si: 0 ft. 5 R. 2 SCH-40 PVC
1fu ail,rppli,able art!pursuit,(r r.County.Moe,Variance,injection, i-.r --
R. R b-
3.Well I'se teheck well awl: 17.SCRIM
Water Supply Well: PROM TO DIAMETER StOTS17r ' nut t.Nrs shrug AI.
❑Agrn:ultmal LIMunictpal'Pnrblic 5 h. 20 ft. 2 .010 SCH-40 PVC
OGeothermal1Healing,Cooling Supply') L)Residennal Water Supplyft. n' r`(single)
GROUT
Obdustrial/Contnnercial I.lResidential Water Supply(shire'd) '
lutist TO MATERIAL [Mn-st f MINT stEnttw A AMOUNT
❑hngation 0 ft. 3 ft. Portland !Pour
Non-Water Supply.Well: R. R. }
I1Mmutonni ❑Recoscn-
lejection Well: ft. ft.
LI Aquifer Recharge ❑Groundwater Renicdiation -19.SAN V[L PACK 1N applied k) 1
room TO SUtrRUI Y.Mpi.ti*snrNr MITttnn
ID Aquifer Storage and Recovers ❑Salinity Harrier 4 R. 20 R, Sand 22
❑Aquifer Test ❑Stonm)ater Drainage
—
n. n.
❑Espcnmcntal Technology. ❑Subsidence Control
26.DRILliNG LOG Wad additional sheets If arcessan t I
❑Geothemwl(Closed Loop) ❑Tracer now TO DESCRwTION stole,hnrdnr,,.,.iil:mil 1)pr.;Arkin vr.rut
❑Geothermal(Heating,'Cooling Return) ❑Other(explain under/21 Rematls) 0 ft. 20 ft. sand
n. ft.
4.Date Wrlltsl Completed: 6-28-24 well lDnl -34
R. ft.
5a.Well Location: R. R. . R .— si 9 t.r
. (
Hamilton Beach R. ft. J l J L 3 T [`J2`!
C
Factlit ,'Onaer Nance Factlil ID/(if applicabk)
ft. It. Jr.
Y.
261 Yadkin Rd., Southern Pines, NC, 28387 n. n, tr�5 ,rs:;: .t•;1^.�
Pbssical Address Cin.and Zip 2L REMARKS ►rk-,3 -�
Moore bentonite seal from 3-4'
u-a,u,h h.ucclItkntdreoinnNit MINI
ib.latitude and longitude in ikgrecs.minutcs.'vcnnils or decimal degrees: 22.Certification:
III ud1 lidd.uua La I,,, ,is strl ra:i.: I)
* W •_ i = f 7/2/2024
Signature ofs� '•?e..:—+-v i i 4ae6 1— -- Daft
6.Is tare)the wrll(st: XPerinanent or 'temporaryBy Mgni,.g liSil flUiri .lid!E*rilirs v:»
�''14�''..f ike:.rl torla k-frd In acronl race
with 1 SA NCAC 02C.•;< `r'-t.•:::l:A. JtC.0200 Wet!Conatrot'non Saor+danis and arat a
7.Is this a repair to an existing well: Jl es or X'Nu. r.S,}o(rhir record bas been provided to the HEN rntwr.
If Mla u a repair,j1!tar*apart and.raw,*row,rarrowr:raal,art I.%Mao;Ow+wane of rho
epairsuder I21 meant..r,iu,,wan rho hrrf of this form. 23.Site diagram or additional well retails:
l ru nla% list tIR•back of this page to pro%Kk additional well site details or well
8.Number of wells coastroctd: 1 :onsuuctlun details. You may also attach additional pages it necessan.
For aialriple orfeerhm or new-wooer.uppit meth ONLY with the WM,coaa racNpa.epa.o..
sauS,nir.a,r/-.rm. SUBMITTAL INSTIJCTIONS
9.Total well depth below lard surface: 20 (f(,i 24a. For All Wells: Submit this foram within ?u days of completion of )sell
for nrail:g'k arms tut an depth ifdigerrn„t•,.,r,.,,l.•. 00200'and 28'!00't constniction to the following-
HI.State water level below lap of easing: (R,1 Division of Water Resources.Information Processing I.nit,
1f neon r 7r,.•t n ;h,,r, ",; ;, 1617 Mail Service Crater.Raleigh,NC 27699-1617
I I.Borehole diameter:8.25" (ha.) 2th.Fur litjtetion Welb ONLY: In addition to sending the form to the address in
24aabose. also submit a copy of this form within 30 days of complexion of well
12.Well tmstntctfon method:HSA wnslnmetion to the follossing.
tic.auger.reran.cable.direct pusk etc.l
Div isles of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699-1636
13a.Yield(Elm) Method of test:
24e.For Water'Nuppls 8 Injection Wells:
Also submit one :ups of this form ss ohm to das s of completion of
lib.Disinfection is pe: __, Amount: well construction to the counts health depanment of the county where
constructed
Form GW.1 Nonh Carob,:,:kpasntclil of Ern immiriu aid Natural Resouwce-Dtsesba of Weir Resotron Res used Algtsst Noll