GW1--00900_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD tor tactual Ilse ONLY:
• This form can bc used far.'single ottnultipk wills. •
1.Well Contractor Information:
.II:-.WATER ZONES-
Brian Ewing PRO'1 TO , orkoHPTtON
Well CotbraaorName, R. ft.
4240-B . it. ft.
NCWcl1CollimatorCcniftcilionNiue/jet' t5'OUTERCASING(furnotil-niseditelstORLiNL'RtfIap'ticable).
Mott TO DIAMETER. THICKNESS AtATrUtAL
SAEDACCO •ft. ft. • is.
Comp;ny.Nape. .!6 INNER'CASING OR TUBING Woli:anal eloscdaoop). -
-PROM TO DIA1tIETER.. .THICKNESS MATERIALPen 2.Wctl Construction ult ti: 0 •'ft; 10' ft. 2 • • bt. SCs-40 ' 'PVC
list all apyilicrrble tre!lpcnaih,fr-e.Comuy;State;Variance.(I a0ut err,:)• •
•i.. ft,- b!, .
3.wcit.L'se(chacicwell use): - 17;SCREEN
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%VaterSupply Well: . , ' . r PROSY. . TO Di.4METER mamma*: TlucttNl i$ I STATRRIAi.
LlAgticuliutal Clhtunicipal/Public 10' It. 20 It; 2 i� 010 SCR-90 PVC I
CIGeotitettnal(HcalingiCaolingSupply} DResidentiatWacer Supply(single) ft. ft.- " in.
0Indusirial/Comniercial i3Residential WVater'Su (slated) ttac GROUT
O.h FROM" . -T .. ' .DIATERLt'• ' EMPL
ACEMENT MR' THOD S AN-10IINT
❑kripation- • 0' • ft. 6 ' R. PORTLAND POURED
Non Water Supply Well: . "
®Monitoring . DRecti3Yty
Injection:Weir:• - n'• . ft. I. : .
f3Atutit`erltccliarge DGioulldti:iicr Reniedialion• -19 SANDJGRAVEL'I ACK(if utrpltcablid'. . ., -'
'PROM TO. ' . NINO:REM.'. • EMPLACEMENTMETHOn .
1]Agdrtcr"Statugcand Rccoycp' (]Salinity l3aitier 8 ' ft.: 20 ft. FILTER I SAND # 2 .
AAquifc Test 056mm'ater Driina& :ft. ft. .
ii.E*ctimcnial Technology • DDSrtbsidcrtcc toning . . .: . _ . .
' `20 DRIP.LING'LOG:(ottackaddlRonalsheel 1Acessen•I
OGeodtennal(ClcsedLoop) ❑Tracer: FROM• .TO DESCRIPTION Irnbr.hanIncn,mnlmekhryr>rainsiratita 1
OGeothenual(Heating/CaolingRetunn . DOther(explain under.f)2IRetuniks) 0 ,rt. 5 . rt. FILL SILTY SAND
' ' 5 -iL 10 ' f. 'MOIST SILTY SAND
12-21-23 TWB06-01' !' '
4.Date Well(s)ConiplelCtl. SYc1l ID(l 10 ft." 20 ft, WET SILTY SAND/CLAY
5a.Wdl Location: ft. f<." I.
NCDOT . ft.' fi, jr_-. Cr—(.�, }:..m, : fr r°".
Facfity,OinncrNatnc. . Facility 1Dk(ifapplicablc) „,`��, 1.<...::`t_' 4-.... .s
ft.: ft.
9920.Mill Branch Rd NW, Ash, NC, 28920 . ' ,ft.. ft. • r f LIf 0 d "LUL4
.P1ty3ieidAddicss City.ini•Zip =21.REILIIAR[:5
Brunswick BENTONITE SEAL FROM 6 TOUEru-r:rri,£:1 ipr.;„F,c4iirr:1 l;i.4 -
CooWy roteottdoitit'ic,1tiouNo,(Pi } 1., :vi:17 x:,L-lw
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56.is dttititte aril Line-Mile in'dc•gtecs/minuteslscctindsor decimal;tegn es: 22,GettificnHnu:' .
(ifsi'ellfeld;'on Li11ougtisuf1leicot}
Brian
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11 �Y Brian 'Ew., i.n 1/4/2024
Sigmtum ofCenificd •
Veil Coninstor- !, .Bate
6.1s•(are).thewell(s):.ElPermaiient .or (Temporary skililrb this form;1 irerciry rerlify thou the ire11(s•/tsw-(Nrrr,J crrnrtnrcted trt msnrtrlmtcr
lath 15A NCAC a2C•AIWO or.I5A NCAC;O2C,O2PD W U Ceirstreierioa Standards and that a
7:Neils a repair to an_eristing well( . OYes Or t Nu :ccpr of flat ward boa h:rn pro irlai to ilia hill mquur.
if th(s'is a nepalr;fill oat Anthill well roastntrdoa brformatlon and rxplaltt'rTia torture of die
repair&der A21 i inrid srcrinn ar on the bail of this form. 23.Site diagram or additional well'.dehills: . •
You may.use the hack Of this page to prot'ide additional well site details or,Well
8.Nmnberof wells Constricted: 1 • coustnlcdotidetiii[s, You may also attach ridditinliat pages ifuecessaty. •
Far'nallti fe lake*ornaat-parer suppfv welts ONLY'rrdrh the same constriicilotr,you.era .
saknrit'one feria.' SUBMITTAL iNSTUCTIONS. ,
9.Total Well Acerb below land surface; 20 - (fL) >24a. for All Welts:.'Submit this foim within-30 days of'completion.of:Weft
For mahlplei,ells list all dirks ifdi,(tertrtt(cranipk-J 2►D'aid2@10O) constnlctionto the following; '
10.Static water level below top of easing: (fh) 11ivisiun of Water Resouney;Infornmtion Processing,;Unit,
If water!eke!is above codas;our"+" 16A7'Mali Sen•icc Center,Raleigh,NC 2769J=1617
IL Borehole tn diactcn 8.25" -;(in.) 24b.For in[mean We1IgONLY: in addition to sending the form to the address,in
. 24a above.also submit a.copy of this(form-within 30 days•of completion of well
12.Well eonstrnctian'method:BORED construction tit the following:-
(i c:auger minty,Cable ditch gush..etc} I
'Division of Water Resources;IIttderground Injection Control Program,
1636 h.htil Service Center.RaleiPic 27699-1636
T�R�YATRRSGPPLYWELLSONLY: II t �,"
13,7.Yidd(dim) 1lcNrod of test:- ?4c.-For•Water Supply-&tnlc ttou4Wctts:
Also subtilit one copy'of'this form Within 30 days of completion of
bit.Disinfeetion.trpe Amount: well'Construction to the calmly Itc.'tti depanme.nt of the.conote.whcrte
' constructed.
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Font;GW-t Noah Caralins tiep in:0d of EntdromtkMl and Nrwrsl Remurees-Dtvsslnp of\WierR ;rot, .Revised August
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