GW1-2022-01323_Well Construction - GW1_20220124

*ELL CONSTRUCTION RECORD For Mental Use ONLY:
This form can to ascd for single or multiple tails
1.Well Contractor Information:
4.'WATER ZONL$
Brian Ewing FROM TO DFS('RlbtlON
tPoit Contractor Maine
4240-B
NC Well Contractor Cenifi.ation Number 15.OUTER CASrNG(for mnHi cnseil McRs'OR 4TPCR tf.s"spot
FROM To nr-a�tFTFR Till kKI MAIT.RUL
SAEDACCO Inc 0 ft. 5 ft. 1" in. I SCH-40 PVC
Cougrml•Name 1b I;NNERVASING`ORTUB1NG edtberrifatekscddar
FROM TO DtAA1. TIIICKNF-SS M.AIT.RIAL
2.Well Construction Pcu'mit a: ft. ft, hi
Litr all ri-Plir able wrl(Pr.mira(i.r.cotouV.Suer.Kiria rrr./4&6cn ele.I e'
3.Well list(clod:well use): 17aCRLEN
Water guiltily Well: FROM I TO I PIANIFT1 R IA)TSIZh 1 TIIICK%rss 1 MATERIAL
OAgricullural 0Municipal/hIblic 5 ft. 15 tt. 1" in• .010 SCH-40 PVC
OGeothemlal(Ncaiing.'Cooling Supply) 011esidential Water Supply(single') ft. ft.
ObidustriatjGotnnicrciai 011csidcntial\V;I(er Supph'(slkated) I&GFROMROBI TO MATERIAL I EAfPtdCT MGVT METTIOD R AMOUNT
❑bTieation ft. ft. I
Non-%rater Supply Well:
h, ft.
®hfonitorinr ORcco,.vey
injection Well: ru. ft.
DAgoifer"Rcclrtrgc 06round7rttcr Rcntcdi;pion 19.SANDIGRAVEG 1'AC.K'Itf i dicoble)
FROM TO MATFRIAI, EMPLACEMENTM1711011
❑AquiferSlorlge and Rctotrry ❑Saliniq•Barrier 3 ft. 15 f1. FILTER SAND # 2
DAgoifcrTest OStommaierDnlinagc ft. ft.
DrNperimnt cal Tcchnology 0,%A-;idrnx Control
20 DRFLUNG I:OGdat rch'additionrl ibeels ihncccs nrt
OGwthemud(Closed Loop) DTracer FROM TO nFSCRIPTiO\(tubr hgrdnei+wdYnKk tt •n 4ie Nca
uGeothetntal(ReatingtCooline Return) DOther(explain under 021 Rentad,.$) 0 ft. 5 ft. FILL SAND/SILT MOIST TO WET
5 A. 15 ft. MOIST SILTY SAND
4.Date Well(s)Completed: 12-2 8-21 Well ID#TMW-3 ft. ff.
Sa.Well LltCation: ft. it. ;i77
rt
2's Tires ft. It.
Facilhn,gOtrrterName Facod%1Dk(ifappliablc) ft. ft.
139 Blowing Rock Blvd., Lenoir, NC, 28645 ft. ft.
Plttsical address.City-.and Zip 21 REDIARKS'
Caldwell BENTONITE SEAL 1 TO 3'
County Parcel Uoifirtcaliwi No (PiN)
ch.Latitude and Lonlhtudc in dcgmcslminuteshcconds or decimal degr ecs: 22.Certification:
(ifwclf Pestd,qi►^,IaL9otig is Srdlicwadl
N „' Bra n.- Ew. ng. 1~,4,2022
Stgnftur;arCenifr d W'c11 Contactor Date
6.6(arc)the well(s): :DPennanent or ZTemporan
M srt+fing rlrls(non,1 herrhr e'e•rtifr rhh+rttr u•rli(sl rsY+s{nrry rv.ruuvrrrJ irr trie'Urrfrmr'r
u•iNr!f,t A`C-AC 02C.(alllY)nr 1 SA A`GtG t1.'.0�>s0!1 nc71 Gnrrsrr,.eti!nr�rmmkrida<uut f)rtn rr
7.Is this a repair to an existing well: MYcs or ONO rapt'of rhry reroni has Bern proeirlrel to Ilm,urll owner,
If tlM i1 t7 telmir,fill emu kru ner well roi)sm rtlmi bl/ornwriom ono explain rho m rwe of(fir
relwir realer 021 rnnarlr sn-jim or ran the bru'l of'this foray, 23.Site dia8rom or additional well details:
You Fluky use the back of this page;to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You ntay also ituach additional pages if oevessar)`.
for omiliple itJeerhm aN nrvt•trarer jtoppfv hells O+V/_y iNth the same construction,you ntn
aul mit one jean, �,1J{MIUAL INSTUCTIONS
9.Total well depth below land surface: 15 (ft.) 24a. For All Wells: Subntil this font within 30 days of completion of ar11
ror maniple ti4h lie all rleprhs ij rllfli rrna fet'ample•J@20n'awl 2e AV)) construction to the folloming7
10.Static water level below top Of Casing' (ft.) Division of Water Resoomm Information Pro tmAng Unit,
lfnvterlewl is nhcree easing,we'•4^ 1617 Mail Senice(;enter,Raleigh,NC 2769J 1617
11.Borehole(IiamCten 2.25^ (in) 24b.For htkrtion Wells ONLY: Iliaddition to sending the form to the.addrt-s in
24a above. also subutil a copy of this fonn within ?O days of completion of well
12.�Vcll construction method: DRIVEN construction to the followine:
0,c.ampm rotary.cable.direct pish etc-)
910sion of Water Rcsoun-es;Unde+'gr'ound injection Control Prograrl.
FOR WATER Sb'PPLY WELLS ONLY: 1636 Mail Sen'ice Center.Raleigh,SC 276"-1636
i3a Yield( ►m) Method of tit 24c.For Water Supply&Injection WelLs:
Also submit one copy of this foini within 30 days of completion of
13b.DiAinfittiOn»pee, Amount _ __ well construction to the county hcnhh department of the county where
commnicied.
Fonn OW-1 Nonli Carobita DcWrl nxv of Erttirorturta and Natural Rewurces-Division of\Yalcr Resouem Reriscd August Z+i l3