GW1--05374_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD For Internal UscONLY.
This form can he imad roc sinek or multiple++ells
1.Well Contractor Information:
14.WATER ZONES
John Eiseman FROM t0 DMACRIPT1O!
Well Contractor Name ft. R,
4439 ft. n.
NC Well CoraiactorCenific'ation Nnn bcr IS.OUTER CASING(for nwelikarcd wells)OR LINFE of rpplicatikl
►ROM TO nisstu FR THICNNEN, \I Mlit,1
SAF.DACCO ►t. I. int.
Contras)Naar: IL INNS LNG OR TUNING trotherita1 ckmed-lump)
FROM TO DIAMETER TOR 6'ET, ,r1ti-11111
2.Well Construction Permit#: 0 ft. 5 ft. 4 los SCH-40 PVC
LW all argue able well pentutI tie.County..Snm.,Varian we.II Sc t etc.) -
ft. ft. ' is
3-We'll Ur(rheck well use I: -I' t('RUN
Water Supply Well: FROM I TO o1+M►Tt.R MOT SOT I 'RI(kNiNS NI%'Mal Al. ,
UAgricultural OMinneipal;Public 5 ft. 30 f1. 4 .010 SCA 90 PVC
OGeothetmal lHeatin �cooli Supply) OResidcntial Water S( ft. h is 1
13 rag 1 P Supply(single)
O hldustria1 Commercial OResidential Water Supply(Aired) 1t'CROUP
FROM TO ' MATERIAL EMPLACEMENT META00 a,AMOUNT
❑Irmantwn 0 ft. 3 ft. Portland Pour
Non-Water Supply Well; n. , ft. —•
El Mont ❑Reeo\rn' -
Injection Well: n. n-
LiAqoiler Recharge ❑Groundwater Rcnicdiation t'+.s.xtiD,GRAVEL PACK(IfapPRraMp)
FnrIM TO MATEEtat. thinIi.ACIrMWST METHOD
I:Aquifer Storage and Recovery ❑Salinity Barrier 4 n. 30 ft. Sand 12
❑Aquifer Test ❑Stommatcr Drainage — —
II. O.
❑Fgxnmental Technnlo(,'< ❑Subsidence Comm! ❑Rn i t\(;TOG ttusch adilgaRal,p(w,if accessary! -
❑Geothermal(Closed Luopi ❑Tracer ERO\t to D -mPnO‘1,.ier,w.roeRrv,,..a'r,w I,IN pr.oral,.ere,stet
❑Geothental(Heating+Cooling Return) ®Other(explain under 021 Remarks) ft. ft.
ft. ft.
4.Date Wela(a)Completed: 8-1-24 Well ins GW-2 - ""
sae Well Location: ft. ft.
International Paper Sports Complex 1t. ft. 5 F P b 9 2024
Foam IN ncr Name Facility 1DN(if applrcat.lc) -----_.__... . fl
Irk,:rA.tfJ i)'' ' --.
289 Service Rd., Canton, NC, 28716 R. ft. DlfrLo' 0:i
Plnsicnl Address,City.and Zip 2L memo
Haywood bentonite seal from 3-4ft
n I'an:clldc,nir ulionNo IPINI
Sb.I.:uitude and Longitude in de rrevminrteslseeonds or decimal degrees: 22.CerdRcathlr:
ill wen field.4111e Lit 10 sag Is s.it 11cutV
s; W ,. ` _= 8/19/2024
Sigmtaic of�r.^� ____a*,��...u.,��.,r`�ci;..`-- -- Date
6.Is lan1 the wellls): RiPcnnanrnt or UTeerperar}• Br,ignikg this fat..c ;1 ..• ei:. ux'i .na.t t.r,ri cwirnartert IR urrardwnsr
with 15.4 NC4C 02C.•;r�r 1-.:M i4A. �;.'C.0200 Wed Cn(utrrr(tira Standards and that,u
7.Is this a repair to an existing is ell: ❑Ye:s or RN° r.uinn r.jrhis et-eon!has here provided to she sir'?owner.
11043 as a repair.fall eawr know*,wells(.+ -m*0,M mfannation and a rplani Me aware of Mr
repair sander/21 remarks seriian or un the had of Chit form. 23.Site diagram or additional N ell(details:
You nlal use the back of this page to proside additional well site details or well
8.Mather of wens oorsfrrcted: 1 construction details. You may also attach additional pages if necessary.
For ma ke*e inkerh>n no NM-Wilk',swpph Welts ONLY with the Mein conatrectian s.r can
sit .n;r :n din.•; SUBMITTAL INSTII(TIONS_.
'1. Total well depth Iretinn land.surface: 30 (f1.) 24a. Fur All Walt: Submit this Iona within 30 dcos of completion of well
for mrhtple wells list oh depths Qdtgerrns le.,owtplr-30200.and 20'1017) construction to the following;
It Static water lesel hellos top of casing: tn.) no isiun of Water Resources,Information Processing l nit.
if wotrt Ir,Co.n ed.arr.as.o; o•. . 1617 Mail Service('enter,Raleigh,NC 27699-1617
II.Borehole diameter:10.625" (in.) 2.lb.for Injection WeibONLY: In addition to sending the form to the address in
24aabuse. also submit a copy of this form within z0 days of completion of nell
12.Well corstrweden method:HSA connsnnictton to the fallowing.
li.c.auger.Form.cable,direct pu.t,:lc i
Disision of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY'WELLS ONLY: 1636 Mail StINICRe Critter.Raleigh.NC 27699-1636
13a Yield lupin) Method rat'n,c .24c.For Water Supple alInjection Wells:
Also submit one: cop, of this form nithun ;0 dint of cotitpktion of
13b.Disinfection t)pc: luunmt: well Constniction to the cuminhealth department of the came'where
.onstructexl
Form GW-1 nuns t aroluia[Averment of Ern inuuixna ant Natural Resources- Dn%ion of Water Rrsoucni Rea toed August 341I+