GW1--05375_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD �� For brow'Use ONLY:
The forum can he used Inc sink tN multiple"ells
1.Wen Contractor Information:
II.WATRR ZONES
John Eisenman VMOM TO DVU(RI►T ION
Wdl Contractor t`auk ft, r6
4439 ft. ft.
NC Well CalumlcsorCenificalion Neater IS,OUTER CASING(far melt eased wells)OR LINER tit ap tirade)
rRON ( TO ' DRNYTTR TNIelOiTs. l NsTTR,(t
SAEDACCO fi. i n. ii.
r linq,: .,Karol: it..INNER CASING OR TUNING stbermatdu -tali)
PROM TO � 7 DUNYTFR TNIfhNYSti N lit NI►L— y
2.Well Construction Permit I: ` 0 ft. 5 ft. 4 la. SCH-40 PVC
Liar all apph•able nod.prrrnal(Le.County.Ssusr,Variance.bhectiat en-.! i------ - -•- - I
IL n. in. L
3.Well I se(check well use): It
lamp
Water Supply Well: FROM 10 Dt.M/Trit st.oTslrr 1 tNICKNIti._J MA1't111AL
LIAgnculttnal [Monicipal,Public 5 R 30 ft. 4 laO10 SCH-40 ; PVC
OGeothennal IHeatingkooling Supply) OResidential Water Supply(single) R 2 IN. 1
❑bdusmriallComniercial OResidcmwl Water Supply(shoed) it
1�
ttttOM to xaTEttuf. EMPLACEMENT METHOD a AMOUNT
Dhngation 0 ft. 3 ft. Portland Pour
Non-Water Supply Well: n. .-1
IL❑hlonitonn), ❑Recuren- ,
Injection Well: n. rt.
❑Aquifer Recharge OGroundwaterRemediation t',.sAND/GRAVELPACK(Naplicahlet
ul)M TO M.(T'RRti1. KMM.A(TMKNTNITUOt
0Aquifcr Storage and Rccos'cn ❑Salinity Barrier 4 R. 30 A. Sand #2
❑Aquifer Test ❑Stormwatcr Drainage
ft. ft.
❑Expenncntal TnhnnloGe ❑Subsidcnc('oruml 20.DRILLING LOG(attach additional~peel►if aecessani
DGeolhemmlIC'IusedLoopi ❑Tracer noon To DESCRIPTION!ter,loodmo....aa wsnIK,vr,sw,dc.1
DGeothemalIHeatingCooliur Retunu N Other I explain under 021 Remarks) n II.
R. ft.
4.Date Weil(al Completed: 8-1-24 Ne-il IDIGW-1 'ft. fL ` , s '• !s'
Se.Well Loratirti: ft ft r U
International Paper Sports Complex n. R. 9 2024
Facility•'OwnerNans Facility MEiifapplicabkl n. R. 111i8.-Rzlf,{;!pi. sry.
289 Service Rd., Canton, NC, 28716 ft n ,o
Plastid Address.City.and Zip 1-21.REMARKS
Haywood bentonite seal from 3-4ft
(.,,np Parcel ldcitdic:ninn No 'PINT
Sit Latitude and Longitude in degrecslmiruetcs/secondsor decimal degrees: 22.Cc refit:miue:
(if well held,one I:mogl:is sunicient t
N q' ��/.� '�_ - 8/19/2024
Sisnnse of ^ '::;%:Ifeio0a s -- •— Dote
6.IN tare)the welts): XI Permanent ur DTemporary Bs Are.if-Win Jiam l ,,,.ic f.s�ttl4 r=l
coaorneled in accordance
with 1 SA NCAC 02C .r-.-r,;,a A..di .0200 Well Creuvrww*t r Swwfurds and that u
7.Is this a repair to an existing sell: DYes or ZNo toy.of Ail record ha,been provided to dn.well owner.
If this u a iepir.fill sru*norm.41,moms POW Mfor70(irltus awl rspiain the nature of Ow
repair ruder 121 remarks mtioir or on the bat-k of this form. 23.Site diagram or additional well details:
1'ou may use die back of this page to pros ide additional well site details or well
8.Number of welb eoltefuctrd 1 cotlstmction details. You units also attach additional pages if itecessan.
For waists*utfetvh,n or non-,tester supph wells ONLY isidi the tame comlraret et i,:u,,.o
.srbmifnee forn. SIIBNIITTAL INSTUCTIONS
9.Thal well depth below lad surfacc 30 (fl,) 24a. For A11 Wells: Submit this foot within 'II lows of completion of well
For maltiplr walls list all depth..ifdrfferrnt i rmnple-?e200'and 2!T 1(NY) construction to the following
10.Static water level below top of easing: (IL) Division of Water Resources,Information Processing I nit.
/t n,o,•t lr,rl n,0...,i ass, ,x-'. 1617 Mad Service(cuter,Raleigh.NC 27699-1617
I I.Borehole diameter:10.625" Ua.l 24b.for[election Weill ONLY: In addition to sending the form to the address in
24a abuse. also submit a copy of this form within 10 days of completion of well
12.Well coestruction method:HSA _ _ comiiruction to the following.
tie.auger.ratan,cable.direct push etc I
Division of Water Resources,Underground Injection Control Programs.
FOR 11 1[ER SUPPLY N I I I -0\11: 1636 Mail Set-,ice Center.Raleigh,NC 2 7699-1 436
t ia.1 MiliLpml Nlcthnd of test: 24e.For'IA Ater Supple &Injection Well:
Also submit one cups of this loon within to das s of completion of
Ills.Disinfection qpc: 'summit: well construction to the county health detainment of the county where
corstnicled
Fenn GW-t Nonh Cacokna Ucpanniem of Ens urrmtn►au and Natural Resources-Disesma of Water Reams Re.used August't'I: