GW1--03607_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD For InternalUse ONIY
This form can be used for singk or multiple wells
1.Well Contractor Information:
Ia.wwTtR ulNls
Brian Ewing ►aOM 10 i DF:N RIPIION
Well Coitrtctor Nana ft. ft.
4240-B ft. fn.
NC Well Contractor Certification Ni1111her 15.OUTER CASING(for meMl-used wells)OR LINER Of Stable)
FROM { TO DIIMTTFR THicksirsi I MATrIltM
SAEDACCO h. n. in.
(rmpam Maine M.INNER CASING OR TUBING igeuIbermal dosed-kepi
FROM TO DIAMETER TRK•K.ESt MATERIAL
2.Well Contraction Permit#: 0 ft. 5 R. 1 I& SCH-40 PVC
List all applicable well permits(Le.County.Soar,Variance.irfl r,c4 err.! ►.
R. R. IL
3.Well I se ichet•I:well use): I7 SCREEN
WaterSuppls Null: FROM TO DI4MrTFR sI.1ITstrr THICKNESS I IdATF.RIAL.
OAgr cultural OMlmicipaliPublic 5 B. 20 ft. 1 i+ .010 SCH-40 PVC
OGeotheal(HeatinglC'ooling Supply) OResidential Water Supply(single) ft. l It is4
m
OhdustrialiCommercial OResidential Water Supply (shored) 1i GROUT mom
PROM TO NAnit-R—� EMFIACTMENT mum°&AMOUNT '
❑lniguttoo It. ft.
Non-Water Supple Well: •
ft. rt.. —
®Monitonnt ❑Rccoveq —_
Injeetloa Will: n. rt.
Aquifer Recharge ❑Ciroundnatcr Remo:Moron 19.SANDIGRAYRL!Mei tir iyrplica let
MOM TO J N1%1111111. F:MPI 14 t1It\l MtT11011
❑Aquifer Storage and Recover ❑Salinity Harrier -_
3 R. 20 ft, FILTER SAND # 2
O Aquifer Test ❑Storm atcr Driin:1w
ft. ft.
OExpenniental Technology. ❑Subsidence Control
2D.DRILUNG LOG MOO additional sheets if nece+tsan t
OGeothennal Closed Loop) ❑Tracer roost To OF.c_RIP riO\.tot.r,haropew,...ito..I.li Ft.era's lire.dr,)
❑Geothen al(Heating/Cooling Return) ❑Other(explain under#t21 Remarks) 0 ft. 5 fL FILL SILT AND SAND
5 ft. 15 fL SILT CLAY MOIST
4.Date Wefts)Completed: 5-14-24 Well IDNTMW-2 15 n 20 ft. WET SILTY SAND
Sa.Wdl Location: ft. n.
W. Cumberland St. PCE Site It. IL -• -..._•..... •-^* / D E tliq•Ow ncr Nang Feed")IDN(if applicablcl ft. h. 'f,I.,.`,r ll.:1 J ft Fu r
1200 Neat Cumberland St. , Dunn, NC , 28334 ft.--,.
re. JUN 1 i� ZOZ4
Physical Address,Oh.and zip 21.REMARKS
Harnett BENTONITE SEAL 1 TO 3' ITtiel1N'i.kf l 7°'r.t. 4
oak
('nun _— ----- Parcel ldc,dific:aliauNn INN' - Dift*C DC4
ib.Latitude and longitude in detpveslminutetlteennds or decimal degrees: 22.certification:
ufyell i'1wld on.:tat long v..Idtickni
N W Brian Ew ii rn g 5/30/2024
Sig uie of Certified Well Con Date
6.Is(are)the wdl(a): ❑Permanent ur MTemporary
ay rigriing din form I hereby certify that the wen(s!Iran(weer)tw arivernd in accordance
WW1 I SA NCAC OK.010)or 154 NCAC(12 C.0200 Well Conurwcnon Sata.lards and char a
7.Is it is a repair to an westing well: Ales or ®No rapj of Air reword has been pros ided M the well owner.
If this it a repair,fill ivrt tivonvi..nil...o>t.K.loon isJ,rrlyalM,,nil rmpkuii the aware of litr
repair wafer 021 remark'.me,-U...,or cm the hark of this form. 23.Site diagram or additional well details:
You may use the buck of this page to provide additional veil site details or hell
It.Number of wells constructed: 1 construction details. You may also:Ittacl1 additional pages if necessary.
i.,.mnlrrpie njrti-runs ma non-water supph wells ONLY wall rllr min.cotrirracaoi t.usi con
Salrmir one forms. SUBMITTAL INSTUCTIONS
9.Total wdl depth below lard srerfe= 20 (ft.) 24a. For AN Wells: Sahnit this form within 30 days of:completion of well
For mrhlple welts Osnall deprhr ifdl(rrenr(eremate-3f 00'and 2Er'tOITI CAn'tnlctlon to the fattening-
10.Static water level below top of casing: (ft•) Division of Water Resources,Information Processing Unit.
If How ir3 rl F.ulamr•aAo o..- '. 1617 Mail Service Center,Raleigh,NC 2 7699-16 1 7
I t.Borehole diameter 2.25" tin.) 24b.For Iniottioa Welt ONLY: In addition to sending the form to the address in
2-raabole. also submit a copy of this form within :z0 days of completion of well
12.We l cofwtnection method: DRIVEN constnictluu to the following
tic.auger.rotas,cable,direct push etc.l
Division of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699.1636
13a.Yield Igpni l Merhnd of test:
24e.For Water Supply 4 Injcctic.n Welty
Also submit one cops of this torn) withal 10 days of completion of
13h_Disinfection'type: %nanlnt well constniction to the county health department of the counts-where
constructed
Form GW-I Nonh Cataluna Department of Ens rroimaut and Natural Resources-Diyatbti of Water Resoiroa Rcs Med Atar.nt?1II