GW1--00859_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD '
Fur itecrunl ifsc ONLY: •
TIi6 form can be used Cot singleai naritipk wells
1.Well Contractor Iufor_ration:
':14.WAITRZONFS
Brian Ewing Pnovi -TO DFSCRIPiION '
11eilContractorNwntc, • R. rt.
4240-H fr. ft;
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NC Well ConlsielotCcttiftcbuoaNuirbcr • ttS OUTER CASING(foriitutu-eisedirctls)ORLINER(ifan flc`UA1t.,
FROM TO , !HAMMER r : Ti11ICKN;SS MATERIAL
SAEDACCo ,fit 11. .In;•
Company Name 26:INNER CASING OR-TUBING(geothermal efased-Ioop)..
FROM .TO• DLoMETER . TttICK iEss MATERIAL
2.Weil Construction Permit#: . . 0 . R. .5 ft: 2 ' 'I!'-, 'SCH-4 0 PVC .
140 0 aplilloilde well perarita,(ir.County;SS,i:d Variagrr.forecdUi etc). --. - -- - - -
• ft. . rt, as
3.Wdl l6se(checl.ildf usoj: n:SC:RILN
Water Supply We l• - ' FROrt'. .1 TO DIAMETER StOTSiZr THICRNttiS I MATERIAL
•CIASricuittital . DMtinicipal/Publ-ic 5' ft. 15 ft; 2 in .OSO SCH-40 PVC
C*011'etmat eatf ft. ft. •in
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(U ggtCooliogSu))p�}'}. ®ResidentialWateeSuppl}(single)
Clindusliial/Conmiercial DRcsidential-Water,Su (shared) te:cRouT• ...
pp '. FRONT TO • .. "ATATERLIL ' t D.
!PLACEMENT MEri-OD&AMOUNT
❑lriipatiun 0 .ft.. '1 -ft. PORTLAND• POURED
Nou Water Supply Welk'
401+.1onitoring ElRecoyety . ,. '.- -,.., - -. ,
Injection Well: . . ft- - ft. .
. itifer I cchargc Dtimuiduticr Rcntcdiation t4 SANDIGRAVEL•PACK fif appllubtc)+. - . :-
FRO�1 TO' stATitRt'.I ! 1' FAIN LAC ADINT!nriiiOn -
17Agnifcr-Storagcand Rceovciy . 1]Salinity Hamer 3• ft; 15 ft.r FILTER SAND # 2
lJAgii for test CIStormi atcr Dnlnaac .
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•ft. f•t;
QF>jtcdmcnlal l octinoto�e DSttbsid¢ncd Conitol- .2u:DRILLING LOG(attach addlttoriul st eels if necessar) - '
DGeorltennal(ClosedLoopj �DTracer ' . .FROM lO •: DESCRIPiiOXtrobrhaMaed.wllIniekille.rJdn.vactal
OGeodtermal(lleaiine/Cooing Return) . DOther(explain miler#21-Remail s) 0 . :ft. 5 ft, FILL SILT.AND SAND
' - 5 ft; 15 ft. WET SANDY SILT
4.Date Wdp(s)Completed: 1-4-24 NeilW#TWB10-01 _ . I .
• f[, fL I . --..
5a.Wdl Lncatlon: L • 't
it ft I - .7 +,L. 't .
NCDOT i1. ' rt. 1 ' F r
Factlity,t ivncrNante . . . .. Facility lB#(Eappliaablc) fG ft.
6900 Holly. Shelter.Rd., Castle Bayne, NC, 28429 . . . :R.. ft.' liy vri-n __r a sa,--r.• G'c_ '+
I'lt43iea1 Audi slL City.plW 2lp. `R•}
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New Hanover BENTONITE SEAL FROM 1 TO 3' ,
Camay (Parcel Wcnhrtealion No.(PIN)
SIi,Latitude and Longitude in degrees/minutes/cconds or decimal degrees: 22 •Certification:
(Ifu IJ field,one*long lc ltdlfricno . .. .
N �V Brie 1 Ewing1/12f2024
Sigattunt of Ccpif,cd Well Coiurlctor Dale
6.Is(are)the wells):.DPer manent -.or 10TemporarY a n(n drix orm,'I'herrb acrr' that din u•e!s luau(isrre)ce nsinrctcrl brae orr!ant
1h'.'s r; I r • tJs Jt J
irin'r(SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Constr+ecdotr Staatards and that a
7.L tltis a repair to an exhit(ngIvdli DYer• or IPNo topic of Mir record Ws peenprotirffd tour nellowner.
if*AI a repair.fill au honor let*coarintcrlaa Ieformnrlan and rvplahrthe wince oldie
repair rvder5V 21 remarkr:iertian Of on the bail ofdds forne ,23.Site diagram or additional well detatts: . . ,
' lrou May-use theback'Of this page to`provide additional ael1 site details or.Weil •
S.Number of wells constructed: 1 . • i:onsttuctioli details. You rimy also allaclt additional pages if u cessary.
FormaidpleI jeerinnorvwtl-waversvplywat(sONLY Oh
submit one form' tr SUBMITTAL, NSTIJCITONS. 1
9.Total well depth helow laud surface: 15 - . (I.) 24a. For All Wells: Submit this forth:within 30-days of conipletion,of.Well
• For muhlplc ii'dislist airdulxhs(f&,Qeu•nt(csampte-:?€200°and 20100) Construction to ihc'following; '
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• 10.Static water level hefuw tap of caslitg ' • - -(fQ.) Diyiviun of Water Rasaurees,'Info mntiun Processing Unit,
If roarer level Is above cad(ax ate"+" 1617'Mail Sen•icc Center,ltalciO,NC 27699-1617
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11.BoreholevHamden 8.25" - •(in.) tab.For Infection WMR,ONLY: in addition to sending the fort to the address in
.24a above.also.submit a copy of tltis.fomr within 30 dal's of completion of well
12.We l construction method:BORED constmction to the following: I' '
(Le,auger,roiarl•,cable'dried gash etc:). L,
'Division at'Water Resources,Underground Injection-Control Prograut, •
FOR WATER SUPPLY WELLS ONLY: - 1636 A(wit Service Centdr,Raleigh NC 27699-1636
1;a.Yield f>;fim1 �lclltod• • test: '2.4e.•ForWater Supply&Injection.Wens; '
• Also submit one copy'of this form s itliin 30„days ofCompletion„of
13h.Disinfectiuutype: Amount: w'ctl-construction to the cotmty health dcpartmert of the.count,.where
constructed. I
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Form GW-t Noah Catalina C1ccpanmam of Hneironnuii and Natural Resources-Division of WaterRmturo Retised Atgust 2013
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