GW1--04575_Well Construction - GW1_20240731

WELL CONS'i'RUC1'ION RECORD For'menial Use ONLY:
Thus fortncan tr a..d for sin{.k of n altMk yells
I.Well Contractor Information:
14.WAfR ZONL8
John Eisenman PROM • TO • iW'CRIPtll)V
Wcll Comm... ._,nK R. h.
4439 ft. ft.
NC Well Counselor Cat ifxallon Nan#er iS.OUTER CASING(far multi-eased wells)OR LINER(if ap likable)
IRON TO , DtAMITPN -MRlE\rfe MATrntA1.
SAEDACCO ft. h. ia.
Coilap;ng N.rlr If.INNER CASING ORTUBING Assiatberssal(•Mre4auop)
IRON 10 r DUMFTFi1 IItI('A\F\5 MATT RI Al
2.Well Construction Permit#: 0 R. 10 ft. 1 2 RI SCH-40 PVC
Liar all..polls ulna.I.r!l peanut,fir.County.State.Variance lryectior1 el..r U
R, II. son.
3.Well I'se(cheek well user: ,fl SCBEZN
MOM Supply Well: OM TO DIAMFTTN it rr1\v1 tHl( NIMS , MATRRIU.
UAgncultural 1Municip:tl/Public 10 R. 30 ft. SCH-40 PVC 2 S. _010
nl tHeatinCooli. R. R to
OGeothem 1
g ng Supply) OResidentialWaterStlpph 'single)
❑IndustriaUComnicrcial OResidentral Water Supply isisited)
1ROM TO MATERIAL. i FA(Pl_A(FMENT METHOD 1 AMOUNT
Olmgatton 0 ft. 5 h. Portland I Pour
Non-Water Supply Well:
R, fa..
H Morutorni ❑RccoA'cn -
injection µ'ell: h. ft.
❑Aquifer Recharge ❑Groundwater Rclncdiation lo.SANDI(:RAVI:I PACKQf soffikaitlr)
YNIIN ' to MATRRtat. rMPI Amer.•TNYTNOD
13Aquifer Storage and Raosry ❑Salinity Barrier 8 ft. 30 ft. Sand #2
❑Aquifer Test ❑S/omns Summit cr Drainage - •
It h.
OE+openmcDlal Taha(TbRc ❑titrhsidcn:c Cnaml hi,DRtI.It il:I.OG larlaeb additional sheets if accessary) —
OGeothemlal(Closed Loop) ❑Tracer ritrst TO_ D►:.t•RrPt If\11.6r,hrtasew,r.a'nui nix.grab mac dc.)
UGeotlrennal IHcating+Cooling Return! ❑Other Iesplant under$21 Remarks' 0 ft 30 h, sand
h. h. 4•• ,j
4.Date Wahl)Completed: 6-28-24 WeilIDI►MW-29 i' "1 V L_.L
Sa.Wcl Location: R, n. - i
— _ .1‘1l 3 A Z01
Hamilton Beach ft. h.
Peak).Oa nee Naate Fortin,, iDN inapplicable) ft, • ft. 's s iw.. ,.yy` 4
261 Yadkin Rd., Southern Pines, NC, 28387 nIII.� ft........_ dik
Phi sisal Addicss.City.and Zip 21.RCMARK S
Moore I bentonite seal from 5-8'
County - Panel Iduadictinn No IPl.i
51►.Latitude anal I.ongitntk in degrreslmit►Rteslaeeunds or decimal degrees: 22.('crtifiealina:
Of sell held.One Ia iletag is stifle tents
�f 7/2/2024
Signaareof ,.-...- •pact; — -- = Date
6.is tare)the silents): %iPermanent or ❑Temporary By sighing this 6.ati t�3‘..lA•ti :•f a.q
I was t«tYet CONVIuelyd to ararrhin.r
with 154 NCAC 02C.•�,..e-,-,T.•:;;(:A.i 1C.0200 Weil Consinlctian SaetS vdi and thus a
7.Ls this a repair to an existing well: DVS:a or ENO rasps of din weary loot been provided to she urn!rooter.
I/iSis it g'true fill nal tnonw urn r..O,Uru.Il.ra infunwrrr.ut and.•plant Ow wrote of the
repair under IZI remarb section or um the ba't of this foram. 23.Site diagram or additional well details:
You ntay use the back of this page to pros ode additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
for ntalrrplr injection.e arul•woter o*ppls wells ONLY..sell Ow sass*constraining u.s.on
submirone fora. SUBMITTAL INSTUCTIONS
9.Total well depth below(rind surfaces 30 (ft.) 24a. for All Wells: Submit this form within In days of completion of well
For mtuttpk nett list all Joule'ifdtflereiu ietuo.ple-to.7iiir aryl'an lint) construction to chc following
Ill.Static water ksel below tip of rashly (R.► Division of Water Resources.Information Processing I nit.
n r'n irhan,a•.. ... 1617 Mail Service('cater,Ralehdi,NC 27699-1617
I I.li:orchok diameter:8.25" Ott 21b.For IDketion Welb ONLY: hi addition to sending the form to the address in
24a abose. also submit a copy of this form within '30 days of completion of well
12.NCI(tun.nrtn•rinn nu•thnil: NSA constnlaction to the following.
Disisinr of Water Resources.Underground Injection Control Program.
FOR W vie St PPl-1 WELLS ONLY: I636 Mail Sets ice Center.Rakish.N( 27Mr1-163(.
I3.s.t kid(::pet) %torrid of test:
24e.For MAC!'Suplils &Injet'lion Wells:
Also submit one copy of this Lunn is ithnt to day s of completion ut
1311.Disinfection type: Amount: well consmetion to the counts health dcpanmenl of the counts where
constructed
Fora GW-t North Carolina Depanmem of Em moment nt and Natural Resources-Ditrsien of Water Rm OUMIS Res red August hit 3