GW1--03624_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or muhipk wens
1.Well Contractor InformaHw:
U.WATZR ZONES
Brian Ewing (ROM i TO Dt!KCRlpttt)Y
Well('ony:low Nam: ft. ft.
fl, : II.
4240-B
NC Welt Contractor Certification Number15.OUTER CASfN(,!for wuNi•canisl wells)OR LINER(ifaDDleabk)
FROM TO PIANITTER THN•KNTSS MATT(MI.
SAEDACCO h. II. is.
(•ontpun Name 14.INNER('ASIN(,OR Ti.BIN(;(,.thermal dme4-lac
IRON r To - DIAMETER THICKNESS MATTIIIAL
2.Well Constraction Permit N: 0 ft. 5 It. 2 w• SCH-40 PVC
LAY all applirrtble well penman li-r.County-Slaty.Variance.IIIiethein etc.! -- -
ft. It s.
3.Well Use felted,:well user: 17.SCRIM
Water Supply Nell:
now TO Duw►TTR curt SILK hello rss M4Ti:111A1.
UAgricultural °Municipal/Public 5 h. 15 Cl. 2 M. .010 SCH-40 PVC
°Geothermal INeating,C'ooling Supply) OResidential Water Supply(single) ft ft. (IL
DhidustriallCommcrcial °Residential Water Supply t shared l lA'GROIIT
FROM TO MATERLIL EMPLACEMENT METHOD i AMOUNT,
❑!ingot ton It. it.
Non-Water Supply Well:
®Monitonne ORecoscry _,
Injection Well: D. O.
❑Aquifer Recharge CICimnndn ucr Rentcdiation 19.SAND(,R Ss I I'Si h iif viol ic Ably t --
I.Rini I. NI tot rlltt FtlPI Si 1 t11\I \11111()1) 1
°Aquifer Storage and Recovery ❑Salitun Harrier ------ - + -------------..------_.__.-_--
3 it 15 (i FILTE;R SA
ND # 2
°Aquifer Tcsl ❑titortmsatcr Drainage 11, u.
❑Expenmcntal Technology. °Subsidence Cotatol
' 211.DRILLING LOG iattach adiitianal stieds if orcessars I
❑Geothermal(Closed Loopl OTracer raow tO DrM RW110N.,,.t.r.laid rs.,..it,.„I. „ ..n Wig,"ICA
OGeotheal IHeate'Cuoltu2 Return DOther(explain under N21 Remadts) 0 ft. 5 W FILL SILT AND SAND
tm m
5 ft. 10 ft. WET SANDY SILT
4.Date Well(s)Completed: 5-16-24 Well 1Di�-1R
1 10 ft. 15 R WET :SILTY SAND
Sa.Mil Location: ft. ft. - _
Ward Citgo 11. It.
!-. 1--�� „.,...1 s t /E L)
Fact lob-(tit ner Name Facllm ID*i if applicable'. ft. IL '
10236 W R Latham St., Clarkton, NC , 28433 B. p •"-t- 1 ii 21124
Ph,sical Address-Cirs.and Zip 21.REMARKS
Bladen BENTONITE SEAL 3 TO 5' leifOi�'i►S ANY Ma►t'.�♦,
cows. Parcel Identification No IPINI
5h.1.1mifudeand Lamgipidc in ell!ri-cs.inioutr.,et iili '.III decimaldegrlees: 22.Certitication:
Of well field.our lairlo rg I.sells.(.:,,
N W Brian Ewiing 5/31/2024
Signature ofCMifted Well Co,' ,., a.:
6.Ie(are)the well(s): X Permanent or T cmlwirars g)signing this faro).1 Aerdry err*Aar lee wrfNsl Inns'(camel cxmrsrurled in aey'ardatlrT
wale 154 NCAC 02C.(lips or 1 SA NCAC t12C.0200 Well Commotion n Seratdarda and char a
7.Is this a repair to an existing well: -1 cs or 'E No raps of"Air record has hers prinirfed re roe well owner
if AO Ia o repair.fill till trwun..rI1..si.71u.,,..n mh.roy.bun unnl r t'ploot row WWrare of the
repair ender I21 rerwarky section or.in rhr bark of this form. 23.Site diagram or additional nett details:
You may use the bail of this page to prom ide additional well site details or well
I.?barber of welb coastrwesed: 1 constriction details. You ilia%also attach additional pages if Itecessan.
For nmaltlpit ittle(-oo t ..,.l-roarer oippls well%ONLY n ult Ow same eananrurti,.n ,..or,on
,abmit one Irn. SI IBMITTAI.INSTUCTIONS
9.Total well depth mhos land surface: 15 (Mt 24a. For Al Wells: Submst tors form within to days of completion of well
For mahtple wells lot all depdo rf drfirrrna reiaatple-tut;00'and 260 117t1) conslnietion In the following
II.Stalk water lesel below top of casing: (D,) Dh isilon of W ater Resources,Information Processing l nit.
If venter kyd t%IA,, .,.. ,: ,.. . 1617 Mail Nen ice(enter,Raleigh,N('27699-1617
II.Borehole diameter:8.25" tin.) 2-lb.Fur Inie tion Welly ONLY: In addition to sending the form to the address in
2laabose. also submit a copy of this form within 10 des of completion of well
12.Well colsolniction method: BORED construction to the following.
ii c.auger.rr4jn,cable.duce p.-'
Dhision of Water Reawrcc..Underground Injection Control Program,
FOR WATER SUPPLY WELL.',(►\I 1: 1636'Slat!'cr't Ice(enter.Raleigh.NC 27699-1636
13a Yield ions) 21c.For Water suppt% &Injs-Lion Meth:
�Icrbnd of trNC
Also submit u1k copy of Ole. lion' withal II datsof completion of
13b.Disinfection hpe: Amount- well constnrctron to the county health delminiunt of the count is here
constructed
Fortin GW-I Lonh C;snohin tkyannrut of Ens Imtut.., Aid Natural Resources-1)ts sine of Wake Reso1ros Res tscd August NI I