GW1--04694_Well Construction - GW1_20230721

• WELL.CONSTRUCTION RECORD Forlr'rvmalUsc ONLY:
Ths.form can iv used 1i r single ar[pullipk wells
1.WeliContractor Information:
•
`t4 WATER-ZONtS . .
Brian Ewing FRos1 TO i D1_$CRIFTIO
«'e1I Coralrtcfor Nitnc ft. ft,
9290-B ft. I fl:
NC Well Contractor Certification Minter ••tS'OUTER CASING(for eiaiti-rased tietlsi OR LlNER1f tfappticabte) _
FRO31 I To ' DIAMETER THICKNFSs MATERIAL 1
• SAEDACCO Inc . . fL fL I I In.
('oiws).H:I.nK': 16.1NNER.CASINGOR=7L1u1NG(lsruatieiinslctaud4o44,1 -'
FROM TO * DIAMETER , THICKNESS ' MATERIAL
2.Well Canstrpetion Perritit#: 0 ft. 29 ft. 1 it, SCH-40 PVC
Lief all applicable wellpenwits(La.County.Seam,t'ariauce,infect cut.L) •rt.. ft. in
3.'Well Use(ehedewell use)? 17:SCREEN
Water r Sulflll\•Well: Fnos1 TO DIAMETER Sr•or5ITZ Tnacus Ss 1 MArERI.AI. a
CIAgriculturat I:MunicipaliPublic 29 It. 39 II. 1 1 in 010 SCH-90• 1 PVC
t' It: in,
®Geothemal(Heating/Cooliug'Supply) Rcsidential•waterSuppl,(single) f I
OludustrialfConlercial ❑Residential Wa(erSuppli(sletmd) '1t3 GROUT: ._ ....,-':-•- .
FRONT -TO. MATERIAL ' EMPLACEMENT.IE IIO0&,4110UNT
❑frripition fL ft.
•Nqu-Water 'ft. ft: . •
tiRilonil9ring DRecavery
Injection Well: • it. ft.. .
fAillltfcrRechargc • DG[oundl►nletR.amcdiatioa , •t9fSANDlGRAVELPACKlifapldiesblii)"' - '
`FROM • TO : - sta.rrau41, - ra1P1-ACr:HENTMiTtiOD
DA 11'1kt Storage and Recovery, ❑Salinity Rattief 27 R. 39 II, FILTER SAND # 2
❑Aquifer Test ❑Stornanatcr i raivaec ft. . ft.
❑ESpetimcntal Tcclmoloiv 1:Subsidence Control
2l.DRILLUNG•LOG7alticli additional shee1s if atcce uw ) • - , I •
❑Geo Oltenia'(ClosedLimp) ❑Tracer FROM To - DR.iatwPTIONtwar.hanlnca.v41,Mxti opt.;min vr.:.dc.i
❑Geotlternlal(Heating Cooling Return) • ❑Other(explain udder#2I-Retnatfss) 0 .ft. 5 • ft. FILL SILT AND SAND
5. ft. 20 ft. MOIST TO WET SILT/.CLAY
4.Date Well(s).Ctmlpletedc 6-21-23 • • -Well ID#TMW-1
20 ft. '39 It. SILT'CLAY MOIST TO WET
5:1.,Well Location: ft. f4 e.. [..-
Auto Truck Transport USA . .ft.. ft, • R ®
Facilily.'OlcracrNniuc Facility iU,v(ifappliablc) R. rt.
.I111 .! 1 2093
1801 N. Main St., Mount Holly, NC, 28120 . ' . ft.. Al. • '
sical Aiidiess.City.and Zi
p ip -2t:REMARKS. in.arrtQtitie.n Prrnzsgatrtid Ui
Gaston BENTONITE SEAL 25 TO 27' CFV&ZIOG
Costs). Parcel IdeatifieMiou No,(PIN} p
. lb..I iititude,anil Longitude in deglTeslminutcslseconds nr decimal dcgiccs: 22.CetTfttratfan:
(if ascll&Id,pare I ti 1OuR iN'sti ficiatd)
s
N • W BrianEwi_n 6/29/2023
• &ammo of Certified Well Contractor, Dale —_
6.Is(care)thewell(s)r pPennanent or ETeulporar}
Nr.;rcning thus farm,-1 hereby eertify rJ1a1.Mg wellis)ma(wtrre)conglireted Marron once
. OM 154 NCiC 02C.0101.7 dr 154 Act('iI 17 WWI.020WI Corstivcrrntt Srandarrfs and t ar a
7.Is this a repair to an ciistiu;;wdli i7Ves or ' ®tin coprnfrhir recaird bits been pnmitlea I th the%ern onvier,
lj'Nu):o repolr.fill oar l.frouer will coninuctirm 41 roaarion trod titpta/n the wrote of the
rr,Rairrurlrr9?1"rcrnarfs.siruan orisa the Lurk ofthisform 23.She dun rnnl oCBdtlltiemaI well details:
You.may use the bad;of this page to..providc additional well site details or Well
S.Number of wells constructed: 1 consulictiou details. You May also attach additional page if tmcessaty.
For nualrlplc lalfeeth!;I or wsa-1cc ra'r supply u.rlls ONLY n'Irh the.saareearrstrgrrlaa,you ecru
bm sait eine form. SUBMITTAL INSTUCTiONS
9.Total welt depth below land surface: 39 (ft.) 24a. For AU Willie Submit this form within 30'days-of completion of well
For nuabiplr icr1Is liar of.'efeprhs fiteii.reru 1,'.raaapfe-.rm?00'aorl.:r'100) consimction to the following:
10.Static water mein[bell ie top of casing: (ft,) Dn t'.iun of Witter Resouree,Information Processing Unit,
1fa'al0/et.!is rebore eolith;:mare"+" 1617 Mail.Service[cuter,Raleigh, 1C 27699-1617
•I1,Borehole ameter:2.25" Oa) 24b.Fir Infection Wells ONLY:
: in addition to•sending the fom)to the address in
24aabove-also submit a copy of this form within 30 days'of completion of Well
12.Well construction method:DRIVEN canstnictitni CO the following
(i.e.auger,rtt:uy,cable.direct posh etc.} Division Of of Water Resources,Underground Injection Control,Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center,Raleigh,NC 27699-1636
I3;1 Yield(Om) Method of test: 24e For Water Supply&Injection Wells:
Also submit one"copy of this form Within 30 days ofcotupletionof
fl36:Disinfection type. Amount: well constmetion to the county hcilth dcpatiment of the county where
constructed. I
I
Form GW-1 Nonll Corollna fkpmuncm of Enciruiuts nt and Natural Resources-Division of Waler R .01.ItIM Revised August 2013
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