GW1-2021-03108_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD For im vntl Use ONLY:
Tits farm can be umd-fm si igte'or mnl ipk%yAs
1.Welt Contractor Information.
.MIM 'tf'ltRIONO
Brian Ewing FROM dP,StTtI, ON
Wctt CorAmcw NAr o
4240-B ft. fL
NG Vitclt ComsactotC¢rilt& ion tYaet
i5.,t)tt7'1?RCA.iING nr' i-agrdieti .t)ilif�t�t. t: U tf "ca yc': `
FROM TO A1AnfETGR' Tttlt'Kt1'F.35 MATERIAL
SAEDACCO Inc 0 ft, 20 tL 1" ►n. SCH-40 PVC
Ce fpnrt)Batt*�6:>I Ci1ll�iGaOR77)BEING' " fd:tf6scd 10D
FROM UTO I DiA.'1IIr'R I TMICiTTSS I MAiF.RIAL
2.Well Conanucdion Peirmtt#: ft. ft. e►
Lira afi eppHruNe writ penafts 00.County,$too,Varioroc-e,It fecdac etch
3.Wdl Use(cheek well ase): _I
n"aYCI Supply Well., OROH TO DtAPIRTRR! $,OT Irtr nsTt:trss MATRR!Ai
bAgficultnfal 0muoidpal/Public 20 ft. 25 ft. 1" is O10 SCE-40 PVC
OGeotheMmal(Heating/Cooling Supph) DResidential Water Supply(sin*) ft• ft' f�
0 tndustfi,I/Commercial aResidential Water Supply(shaied) Rost FROM
>: TO P.atPuca�.sfgvT MsmoD fi wMotiNr
❑trti lion tt. b:
lien-WnteirSupply Well: ft. ft.
t�itiloiritoti DRocm '
Injection Well: h. ft.
DAgvtfer Recharge 0arundvmter Remodiatiott
t7AgttifcrStoiagetildRe:em DSalin` flames FR H 1AT t I. ,Maa.a *_R� rTtr n
v 18 ft. 25 ft. I FILTER SAND # 2
CAgnifer 1cst 08tommatcr Aminaie
0EXpritmcntai 100molpa 0SAsidencc Control 203itit t:IKtl't lit"faitiicl,'tie8lit
lit:`lic+dsifs3i
DGeothemml(Closet Loop) OTtaoer FROM I TO DT6GTtrrirOX Ql17r l�Af�hl StiWmets n etc N�
13Geothennal(HeatiftlCooll1r,Return) 130ther(explain under#21ReNift 0 ft. 20' (L FILL SILTY SAND
20, ft. 40' ft. WET SILTY SAND t. -
4.Date Well(s)Completed: 6-3-21 WdlW#TMW-6
So.Well 6wation: (L IL
Willis Grocery/Crossroads Pet Supplies fn. M
FWHi1y'MVoerNam Facility lDN(ifapplzable) ft. n.
C,C�sSt
4025 West NC Hwy 10, Newton, NC, 28658 R. M,
Pb.v* l Addmss City-and Zip 2I NZA
Catawba BENTONITE SEAL 16 TO 18''
Cuumy Farrel idemort at on No,(KNI)
ft.Witbde and lAinAitatic in dcgrmr4mlimtcsisecnnds or dccimai degree: 22.Certirw2tion:
(If»tit hold,aye 110org is S1dfrcind.)
1, W —Brian a n Ewing. /2021
6.Is(are)the weil(s).aPermanent or oTemporat}
Br stiOng AltfmM thereby ay.n*:t/&nor urtlls)iwx 1 wirm)txmwmaed in ae'aoi�ce
elite 15A NCAC 02C.0100 or MA NC'AC 02C.02M RIM Cr mowi;tan SwdaWs oM that d
T.I-s this a repair to an wilting well: oYes or MNo ropy afthit twor f ho lwm pre*4 to 00 viril aum Pr.
tf Ali Is a frpdr.fill eat Amite uv11 ro+oitrurtton lgfarmailw and evfaN Me 01drure of die
revafr anderf21 remarb srawn or ac rim boil of this form. 23.Site dtatrom or additional well detaffs:
You limy Use the back of this page.to pmide additional hell site details or well
S.Nomberaf wells constiveted: 1 c ousttuctiondetails. You may 4110 attach additional pages if tecessmy.
For nud4plei erzWor"(A-»mricop*-wrq�s01VE)nsfmdkunnrrnnsrracdont 'WNcap cml�iFITAI.INCTtC14o1�C
rubnut ene force
9.Total well depth below land surfaces 3 9 (1k} Saa..Fer All Wells: Submit this,form within 30 dM of 060pletion of a'eit
For multWr KWU list alittexks If4ijJermi ecrsaevk,Je20 i'end 201fiV) con5tnwtion to the following:
10.Ststle water IMT1 below top of sassing (ft,) Divislon of Water Rtcourrtes.It fotmstion Processing Unit,
tf H vtrrr AeWl is dhO&e MAX,RM°+" 1619 Una Soviet tenter.Raleigh,NC 276"4617
It.Borehole diameter 2.25 00.) 24b.F-or lnlecttttn'Wel1s ONLY.#-in addition to sending the fomn to the address in
24oabove. also submit a copy ofitids form within 30 dais of completion of well
I L Well constmetion method:DRIVEN concoction to the tbllowing:
ti.e.;aupr,minty,able,direct posh etc:) E
1ltvhlonof Water R.esouaces Undcrfpnund Injection Control Program.
FOR WATER SUPPLY WEL[.S ONLY: 1636 Mail Service Center.Ruleto,NC 176"1636
13a.Vidd(gpm) Method of test Ur-For Water SnpMj&tnjolamts Wells:
Also submit otw cop} of this fonn'ivithin 30 days of completion of
well construction to the coamh n hcMih dcpmt cin of the county where
13b.;Dlsfnfoetnn tin Amount constmcted.
Farm GAV-t Nonb Camlina Dotmtmut of Easimnmu and l nail Resotms—DnisMn of R'stm RED Re%-Iwd AL5t 2013,
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