GW1-2022-01324_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD For hicntil Use ONLY:
This fonnean be aw¢d for single or mtsltipk%ells
1,Well Contractor Information:
14.WATER?.ONIS ,
Brian Ewing FROM TO I DESCRIPTION
Well Currtnclot Namc A. ft.
rt. tt.
4240-B
..1S:OUTP.R CA$tNG far multi-ciikkd is s OR GtKER H:a D Ikahk
NC\1rdfContr�clorC.nifecationNun$cr FRou TO DIAMETER THtCWNT-Is MATER1A6
SAEDACCO Inc 0 ft. 5 It. 1" in. SCH-40 PVC
l ongntriy a\ante t6 INNER.-OR TUBING.( it All&wdaolrp'
PROM TO I DLAMFTER THICKNESS MAnRIAL
2.Well Construction Permit N: ft. h. 1hl.
List all al:prlirable writ prnrrils li_r.C,ounh•..Stwe.1'nriaorr,Ifixtlat em.1 fl. (Iin.
3,Well lisc(chock well use): 1T SCRUN
Wa1erSupply Well: FROM METE TO DIAR „'. SId1TS17E I THIC10r\S i NATFRIAI:
C)Agricultural 0Municipol/Public 5 ft. 15 ft. 1 i^• ' .001 SCH 40 PVC
iJGeothcmtal(FicatingrCooling Supph') OResidtntial Rratcr Suppl> (single) ft• ft• in.
f)tndustriaUComuncrcial I:1Rcsidtntial Water Supph•(shared) 19.
GROUTFROM TO MATF.Ru'l. P.MPt.ALY.MGVT METTIOU A A%IOI(N7
01"i ation ft. fL
Non-Water Supply•Well:
@Monitoring ❑Rccovcry
injection Well: ft. rL
DAquifcrRcchargc DGronndn;ttcrItcowdiation 19.SANDIGRAVEL PACK"iif dkabte
YR/,IM TO MATERt.At• N\1PLnC'i;11FSYNfCYHl111
❑Aquifer Siorigc and Recovvy ❑Salinity'Harrier 3 fl. 15 ft. FILTER' SAND # 2
DAgnifer Tcst OStornmatcr Drtinagc
❑Experimental Technoto&%• ❑Subsidence Control
20.DRILLING LOG(aitach`additionel!ilitets it acce'"ryi-
DGmitennal(Closedloop) OTrtcer FROM To 11PSCRIPiiONk*br.Fxrdnccvt,Mi1%'^rkfv drSva,Nc:l
OGeotltemlal(HeatiketCooline Return) DOther(explain odder#21 RetnaAs) 0 ft. 5 ft. FILL SAND/SILT MOIST TO WET
5 ft. 15 It. MOIST SILTY SAND
4.Date Well(s)Completed- 12-28-21 Well ID#TMw-2 ft. ft.
it.WL41 I-Aicathln: ft. ft.
2's Tires ft. h. JAN 1) � q
Faci1H)•'OnncrNantc FncilHylDk(ifapplitiblc> fl. ft. ��L-GE:,
139 Blowing Rock Blvd., Lenoir, NC, 28645 fa ft.
Ph)sienl Address.City.and Zip 2L RCiNARKS
Caldwell BENTONITE SEAL 1 TO 3e
County Mime]ldewiric:nion No (Pink
Sh,Latitude and Longitude in degrecslminutcslsccondc nr decimal degrres: 22.Certification:
(if arell lwld,one laltlntV is sidlici ta)
1/4 2022M...._
Ggruurrc of Ccniftcd Well Contriver Dale
6.is(arc)the well(s): DPennanent or RiTentporan' M sig,ti,t} this fim",1 he•rehr crefify thof the"rdfsl nws fwrre)Cnnvfrarted ire rrccorrlirnre
with 1 SA NCAC WC.(Ufkl it,1,m A'CAC•o2C.02011 Well Coagn,Crirtt$tamhlrtls turd flat o
7.Ls this a repair to an existing well: ❑Ves or CE N11 c,pn of this rccan!lea,,hrrsr pmrlrl•rP ra tM,1ri1 nu'nrr,
If this i,a tegxt)r,fill two(rom we11 htforuurrion and explabt the nature of the
relurir mreler S21 rromrAw.rr..•fion or rut the hrwl of iltis form. 23.Site diagram or additional well details:
You may use i1K back of this page to pror'ide additional well site details or well
8.Number of wells constructed: 1 consuuction details. You may also attach additional pages if wessary.
For mnblple infeerkm or ntritnrare•r soppy wells ON9.Y wlth the some rnnsrrurdon,curt can
swbmit one torn. SUBMITTAL INSIUCTIONS
9.Total well depth below land surface 15 (ft.) 24a. For All Wellx: Subndl this:form within 30 days of completion of well
For wahlple wells fist aft dep itts iftllffervii fermnp(e•?@209'i"td 20100) constmetion to the fallowing
10.Static water level below top of casing: (ft.) M ision of Water Resources,Information'Proccising Unit,
lfn'alet letrl Ri M-ot'e casing,ate"+" 1617 Mail Sm•ice Center,Raleigh,NC 27699-1617
11.Borehole diameter.2.25" (in l 22b.For Injeetion Well,ONLY: lit addition to sending the tome to the address in
24a above. also submit a copy of this form within 30 days of completion of well
12.Well construction method: DRIVEN construction to Zile followilwL:
(i.e.aogcr.rota*,.cable.direct push etc-)
Division of Water Resources,Underground injection Control Pingram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,\C 276994636
13al'idd(gum) Alethod of test: lac.For Water Supply&Iniccfion'Wc1Ic:
Also submit one cop), of this form tiithin 30 days of completion of
13h.Disinfation t,pe _ Amount well constmclion to the county' health depnnmeru of the cmmh•where
constructed.
Fonn G1,Y•1 North Cstotina ftanntctn of Emirmunctu and Natural Resoutces-Uivisioo of Wim Resotroes Rcs•iscd AiguSt:K)13