GW1--05376_Well Construction - GW1_20240909

,
WELL CONSTRUCTION RECORD FOf Internal use ONLY:
The form con to ns d floc cingk or multiple sells
1.Will Contractor Information:
II.NAttRZONiS
John Eigenman FNaust to j ee.cRnrtiox
Well Contricmt Name ft. 0,
ft. (h
4439
NC Well Contractor Cot ificalion Number15,OUTER CASING(for dhi•caxrl ecNsl OR LINER die ap likable)
Mom l TO INlMFTFR THN'KNr s Al'TlNISI
SAEDACCO Itn. ia.
Coupon)Name S.INN=.RCASING OR TURING troilb:rmal clued-ieop)
/ROM TO t DIAMFTFH Intl( FJS shin Rift.
2.Weil Construction Permit 8: 0 ft. 5 ft. I 4 lc SCH-40 T PVC
•
lea all applicable w4Npeneihh(ice.County.Stair,Variance.lgeefiarf err.) - - -
ft. R. I rt.
(check
3.Well Use well est): 17 SCRIM111 —
WaterSupply Well: /IIOM TO ot'MVTFR 4O181)7. THrcxrrie I WArrrl+t.
1_IA(trwuhutal OMunicipalPub6c 5 R. 30 ft. 4 im• `.010 SCH-40 PVC
11(;eothetttal iHeatin ACooling Supply) OResidcntial Water Supplyh' h' M g (singlel
I I Industria1Cornntercial OResidentwl Water Supply(shored/ 18'CROOT
PitOM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
O'meat ion , 0 ft. 3 ft. Portland Pour
Non-Water Supply Well: ,
It. s ft.
❑Monitoring ❑Rceovcn-
Injection Well: II. n.
❑,Aquifer Recharge ❑Groundwater Rcntcdiation I).NAND(.Ref EI.PM h of applied/fell
IRON i_,L,, StATkuWt. PMPI.%CTAIWNTMITHOD
I:Aquifer Storage and Recover, ❑Salinity.Harrier 4 ft. 30 ft. Sand #2
0 Aquifer Test ❑Stommater Drainage ft. R.
❑Espenmrntvl Ttihnolo}'< ❑Subsidcrcc Comm! N.DRILLING LOG iallackeediuoaal sheets if merman)
OGeothemal(Closed Loops ❑Tracer r'NOM TO DESCRIPTION t,ebr,lieNaent,w,YtMck ene,nrale gm,OM
OGeothemal tHeanna.C•uoliug Return) ® d Other(explain under al I Rcmasl ft. R.
ft. h
4.Date Wells)Completed: 8-1-24 Well IDi GS4-3 ft. ft. 6 - r -.. T.4.!1 Si. r-
Well Location: 1t. ft. ' \ I t ' 1—.Lf
International Paper Sports Complex h. D. SEr® d 9 ZU24
Facility Outtcr Name Ewalt!.(DN(if applicable) n. ft.
• Cia 1Tk:1 :++.. ittr sp.=:_y
289 Service Rd., Canton, NC Haywood County, Canton, NC, ' ti_ ft. a•^ 4
28716 Physical Address_City.and Zip 1 21.RCINARKS .
Haywood bentonite seal from 3-4ft
(:oasts Parcel Identification No IPINI
Sb.Latitude and Longitude in degyeeslinimitesiseconds or decimal degrees: 22.CeetlReatlM:
(if welt held.roc:IaWtogg is sufficient)
signalise -mac:�+t•'K�=yw±r.ai.�-- -- [hue
6.Is tare)the nabs): 30Prnmanent or ❑ ra Tempory Bysil(nirr faa„ ;;c' frIViiA•a' u.'s o i cumin/tied in anordarrn
Kim 114 NCAC'O2C.•1, --7:•::il'A...JC.0200 Well Cmtarrwrrian Standards tam duo a
7.Is this a repair to an existing well: JYex or RNe rape nfthi,,,--.rd her,her,,pr,;,-1.1•,1 to ra:..,141.wrier.
if Otis at a repair,IN net 4ntown well t oe,ink low mfornrnrim(nil explain the satire of the
rep..',n„L r 021 rem ark..w-,ms,or OR the hod of this form. 23.Site diagram or additional n ell details:
You may use the back of this page to pros ide additional well site details or well
8.'s um,l1c r of cells ettuetrxcted: 1 construction details. You trap also attach additional pages if Itecessan.
I .i,n owl-Heiler tuppi•„I'll,OiN!.L made the tmrm,cansrracaew.Woe two
$UBMIrrAL INSTUCTIONS
9.Total will depth below lard surface 30 (n.1 24a. For All Wells: Submit this limn iithm 7t1 days of completion of nell
For.oulrtplrurllsaisr Id/drlvhrifdift rem 1f.raapk-30200'rind 2 'l0Ol construction to the folloning-
iu.''[metecaterIntlbelowttapofrasiev (fy1 Division of Water Resources,Information Processing.(nit.
„4 + 1617 Mail Semite['cater,Raleigh,NC 27699-1617
t I.Ili rchuk diameter:10.625" (hr.) 24b.for injSrtion Welb ONLY: In addition to sending the form to the address in
24aabose. also submit a copy of this form nithin 10 days of completion of cell
12.Nell construction method:NSA construction to the((Atoning.
g.
n e.auger.roan.cable.direct puck ele.I
Disision of Water Resources,UnderNruu.nd injection Control Program.
FOR WATER SUPPLY WELLS ONI 1': I6d6 Mail Serer ice Center.Raleigh.NC'27699-1636
24c.For N titer Supph .L• Injection Wells:
I 3a.ti did IRpm/ Method of rest:
Also submit one cops of this form is thin 10 days of-completion oh
I3b.Disinfection ispc Ammon: construction to the county health depanmtnit of the county(there
erowar ictcd
FormGW-1 North Carolina tl.punnictu of Em irotutrm aid Natural Resources-Dit loon of W'aict Rmotmes R:.red,August v'I