GW1-2022-01325_Well Construction - GW1_20220124

WELL CONs'rRUCTION RECORD For internal Use ONLY:
This forin can be ti%cd for single or multiple wclls
1.Well Contractor Information:
_44.VAURZONVS-""'
Brian Ewing FROM To WSCRIP"014
%Veil Cortm clot Nittic
4240-B
NC Well Conlraclor Cenificit ion Noniber 15.VUTVR CASING(for RLINTR(ifiniIkMe),
FROM I TO WAIMETrit Tll1CKNVS5 I MATTRtAl,
SAEDACCO Inc 0 ft. 5 ft. J.' in. SCH-40 PVC
Convalls Nallic _116MINNER- ING&RIP111111 Gtgtolkero to dWu%ed400__
FROM TO DLANIFTER
2.Well Construction Permit A. ft.
list all rpPlirable well prn"itx(ix.courit.y.Ster...
3.Well Vic(check well use):
Water Supply Well: FROM 1 70 PlAW.TER SIX)TS11F, MATV.111M.
OAgricultural Municipal/Niblic 5 15 h. 1.251, in- .010 ISCH-40 PVC
0Gcothenrial(licit i ng,Cooli qgg Supply) 1311csidential Wiler Stipph'(single) in.
01ndustrial/Coninicircial ORcsidcnfial Water Supply(shared) -I&GRUTO 7
FROM TO -SIATERW, I L%lPtACTMCN'TJ%1rn10D R AMOUNT
0hrigation
Non-Water Supply Well:
A. ft.
0hionildrittg ORccoNvy
injection Well:
DAquiferAccliarg 06roundni-nicr Rcowdi.nion A9.SANDIGRAVEL PACK ILI tNicahle
TO
0Aquifer Siorigi:and Rccovcn, DSalinilv Hirricr _T F.mp,I.A M..WN'T!W311011
3 A. 15 A. FILTER! SAND # 2
OArinikir Test 0slorriam-aicr Drainage ft. ft.
0E%:perimcntal Technology 0Sub5idcncc Corcrol 10.DRILUNG LOG(attach additionals"%if necessany) 7
oCkothennal(Closed Loop) oTraceir FROM T(1 DESCRIPTION((*br.hurd"Vci,010"ick eviit.ertin Ale."t.1
ElGeothennal(RcatinatCooline Return) 00thcr(explain under#21 lkeoiaris) 0 ft. 5 ft. FILL SAND/SILT MOIST TO WET
5 ft. 15 ft. MOIST SILTY SAND
4.Date Well(s)Completed: 12-28-21 Well in#TMW-1 ft. ff.
Sa.Well Location: ft. fl.
2's Tires
Facil4)-)0%%ncrNainc FactiHN.im(irVpi*_,blc)
14. 11. 4
139 Blowing Rock Blvd., Lenoir, NC, 28645 ft. ft.
Pik%sical Addicss.City.and Zip 21.REMARKS'
Caldwell BENTONITE SEAL I TO 31
Nt%;cl 1&nairscaliun No.(PW.)
Sb.Latitude and 11.ongitudc in depws/minutesisecrinds or decimal degree.-: 22.Certification:
df%wli Acid,onc latloog issidficixul)
Bri.aaf Ni11g 1/4/2022
Sigmtor,ofCcitificd Well Contractor Date
6.hi(am)the well(s): OPennanctit or ZTemporary b%�signing INsfirim.I heeb r I.rfl;f"dito the wi-ellfs)tsws fmrie)ranvinit-I&I in m-cor(lanve
wirlt 154AICAC 01C.01(y)or 15,1 NOW nX,0200 Well ConsmiriOn Stan4aids mid VAYl
7.L%this a repair to an exivdng well: Oyes or 11,No copy of this rerolyl ha'%been p1m,ld"d to Ilre 11Y.11 awner,
IfI613 is a lepair,fill mir 4volm uyll ronsmirfirill Deftly irlon and explerl-I the meare of dir
reprit rt,Tejer or evi thr lo"k qfthixJana. 23.Site diagram or additional welfiletails:
You may use five bac6 of this page io piovide addifioital well site details or weil
8.Number of wells constructed: 1 construction details. You way also attach additional pages if necessary.
For maniple inje,441m&nevi-woler jvjjpjk�v ii-eth 04VIA,I&II#hr some ron.sir"efion,'VoU Can
.taNnitime forri. stlaminAL iNsTucTioNs
9.Total well depth below land surface: 15 ft.) 24a. For All Wells: Subnlil this;fora) within 30 days of completion of well
l6i all depths Iftilffirrew(extirnple-3ON100'awl 20 W) construction to the following;
10.Static water level below top of casing: (ft.) DIA-ishin of Water Resources,Information Processing Unit.
If.swer level Is above casing,use"4• 1617 Mail Service(.enter.Raleigh.NC 27699-1617
11.Borehole diameter-2-2 5" On. 24lb.ftrj#lb:gjJjjaM1L�i0NLV: lit addition to sending_q the forni to the address in
24aabove. also submit a copy of this form within 'iO days of completion of well
12.Well comstiruction method: DRIVEN Construction to the folio%%ilw�
L
(i.e.auger.roiary,cable-,direct push.etc.)
Division of Water Resources,Underground Injection Control Pmgram.
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Scr%ice Center.Raleigh.NC 27699-1630
13a.Vield(gpm) Method of test: 24c.For Water Supply&Iniccilion,Wells:
Also submit one copy of this forni within 30 days ofcouripletion of
,.veil cominiclion to the county hen I hit dcitnitment of the county"-here
13b.Disinfixtion type: Amount: contracted.
Form OW-1 North Catolina DWnient of Environment aid-Nitsiral Resources-Uaviiion of Waici Resources RcN-iscd Atigust'-N,13