GW1-2021-03112_Well Construction - GW1_20210625

WELL CONSTRUCTION RECORD ForltatroolUyc()tJt.Y:
n.is form con be amd.fat siigk or od i*hells
1.Well Cont actorinformatlon:
Brian Ewing PROM I To I OM.MIM1ON
volt)CotltatctoT tt'ame tt' h• I .
4240-B ft. M
NC Well CommorCeitifimianNuirber IS,Off_ td/ta ts+ttl 17rrgR flcati
PROM TO VIAM"M " I MAiEAIAi.
SAEDACCO Inc 0 h. 20 h. 1° jis. SCH-40 PVC
cdavodly A'aelc I6 1+T"k, 1PfG ►et+eb .:-. . {.
FROM TO DtAMrm MAIrRIAL
2.'WdlConstruction Pertain It. ft. IL in
I"#11apptimmo.wol permits ti.:Counn,3t�r,Vnrinnrr,lr�ectlGrl rtr 1
h. fl. ill.
3.Well Use(dmck well use):
WaterSopplh Wdh PROM TO 01A1%1RW M 1 -noGlcWYss MA•t`P.RIAL
f Agl clrlmtal Ql1tIt0iClpQil/t'It�fiiC 20 ft. 25 4. 1° 1% .010 SCH-40 PVC
Moothermal(Hentingtooting Supply) QResidemiai Water Suppb,(s'rn&) 11. IL in
DlndustrilfiComfiridal QResidential Water Su
ppl)(strtree!) FROM 1 TO MATERui: n1F1 ACV.4 VCTML'M0D&AMOUV.t
❑ltfi Non. 'tt. h.
loom.Water Supply Well:
i&Monitor !]Ilex of h, ft.
Injection Wdt: h'
QAtptifcr'Rcehirge 0droundwate:rRemediation 19. D F
QAgnifcr Stodge and Recoveq QSalinifv brief FROM tat elAt. roar A, t/YT NiTie n
18 ft. 25 fl:. FILTSRj SAND # 2
QAquiler Te:h l3Stommatcr Dm nagc
E3kxpcltmcntalT=hno1oW cist ilenccControl AM"bitilab 6Vitifi,eli ilQNt a1E
s .
DGootimnal(Closed Loop) t3TMM .PROM TO DIMCRW"ON,mbr."Mom a livnsa ty PC.OWO fts nG
QGeothenual 1 katingCoolingRetum) 00dtr ( lain under021 Remade) 0 ft. 20, n. FILL SILTY SAND
20' h: 27' h. WET SILTY SAND
4.DateWW(0)Completed., 6-4-21 WdllD#TMW-13 ft. (L
Sm.Well (L IL
Willis Grocery/Crossroads Pet Supplies rL h. ,
FwHiiylOwnerNamc Fhctlq lD#(9fspplicab16) ft. h.
4025 West NC Hwy 10, Newton, NC, 28658 h. h. ��cs �lS►�
Ploikd Addttst 01 .and Zip
Catawba BENTONITB SEAL 16 TO 18'
00VW Pattetlderd,ffluoallo,(PPA)
5b.14aitiade and 1,6ngtmdeindegmahnimlwlsc6ndsordecimaldegrcr 22.Cettifxatign:
Otutlt 1100K ark r 01r,is pdfleko)
W Brian Ewi ng 6/9/2021
signitux of Gnttfied Wai Cantteems t)atc
6.U(late)the wt l(s): 12mnaneot or oTemporae} Mr.stgmn ,dds farm! _ r rhr the call{#i Kmr/r M!cvnirmrrled i+i err
n•11A 1,3A NCAC 02C.01M or ISA NCAC 02G.0200 1i'r11 Comma at Stmdmds and dui a
7.Is tbic u repair to an elddsting well 01'ft or VNo cops ofthlr rav oaf hat lwm pmrf*d to Ow urli owner.
If*ls!x a/rpa ,flit out tx irm urll r oar notom iatlorma ion and explain,the narrre r f fir
nWirw dertr?1 remarks section or m the Bark of this form. 23.Site diagram nr addltional well detatht.
You m my we the back of difs page to pw%ide additional 1well site details or well
8.1•`ttmbcrof+sells nonstructed: 1 construction details. You may 9190 atteeb additional pages if necessary.
For malilr4e 1/erdwi or wm-»mer xlpi*wells ONLY"i(th the wmt x �TRM2ITAL.I1\+<TUf"t'tOj
"Omit sae fors,
9.Total well depth below land surfate: 27 (r(.) Z4a. For A Wtlls Submit this fnml vdibin 30 dims of ootnpletion of well
For owtople n:yus nirwildepos(ldl crew rmc to 3 3(1f►`Sm 201w) constnic ion to ftfolloning:
10.Stine water level below top of rasing: (R,) Division of Water Rrso6r&&laftrrmation Pnoeessing Unit,
if w atrr keel Qborti ms1nS,wr";" 1617 Mail Service Cato.Raleigh,NC 276944617
4
11.Bordwic diameter:2.25 (in.) 24b.Ebr inMtticln Walks ONLY: In addition to sending ft form to the address in
24n above. also submit a copy of this form crithin 30 0-s of completion of well
I L VVdl Coft5"Ctlol,rnetbod:DRIVEN constmelion to the following:
(i.e.strsix,mtar);cable diw pash.cie.)
Division of Water liesoDn+ m Ur tee"und Tojectioe Control Ftugfam.
FOR WATER SUPPi Y 1WTLLS ONLY: 1636 Mall Somlcc Canter.Raleigh,NC17bn91636
13a.l"idd(gpm) Mcthod Of test 2�For Water SoT181..F&injoattm NVells
.Also submit one copy of this fend rtitbin 30 days of completion of
13b.'Disinfection try Amount: well consiniction to tort county he olth dcpahment of the coui*,where
coustmcted.
Fawn M-t NoAh Camlina Dq►atnmttof Emimnr"and W u W Rmv=s—D-hisiion of%' RtS WM Rc%-ked t 2013