GW1--03736_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD For l,sered Use ONLY:
This form can be used for single or mutt ask wells
1.Well Contractor information:
14,WATER ZONES
Brian Ewing PIIOM to mow RIP1ION
Well Contractor Name p, ft.
nc
ft, n.
4240-B
Id.OUTER CASING(for sneMi cased wens)OR LINER(if taltllncahle)
NC Well Contractor CcnificationNrmlber FROM TO DIAMETER THH'tiAicS MATERtAI
SAEDACCO fi. 1 ft. is.
Company Name Is.INNER_ CASING°. SING(geothermal dltw0datio]
FROM t TO DIAMETER THICKNESS MATERIAL
2,Well Co.tm glint Petwlit M: HI0100715 R. ft. ie.
Liu all apphinble well penniri(ix.County.Stier.Variance.b1'eCtiOt en.l
fl. I ft. in
3.Well Use(cheek well use):
17.SCREEN
Water Supply Well: VIIOM TO mixture 4t.OT Spa tuft-toms j %ATFRMAL.
LIAgr►cultural OMunicipal.Public rt. is._
Meeting/Cooling R' rt. i"'[JGeothemlal �tiglCoolit>K Supply) ❑Residcntwl Water tsingle)
El Industrial/Commcrcial ❑Residential Water Supply(shored) it.
PROM TO MATERIAL-. EMPLACEMENT METHOD A AMOUNT
❑Irrigation It. ft.
Nou-Water Supply Well: H
❑Monitoring ❑Rceovcr -
IRJeetio.Well: ft. It.
°Aquifer Recharge DGroundw:aterRcinediation t!.SANIN(IRAVIL Melt ofaft(plk.sMe)
VNOM TO M%l-FRt%t. r:MPt.ICI'MFNT MFTIRIIi
°Aquifer Storage and Recovery ❑Salinity earner h. ft.
❑Aquifer Test ❑Siornnsatcr Drainage ft. ft.
OExpenmcntal Technology ❑Suhsidcncc Control
2e.DRILLING LOG Iagoeh additional sheets if see ssan I
OGeothetuud(Closed Loop) ❑Tracer MOM TO DFw RIPt6►N l,..6r.u..rdn.•,,,,.LOLL.I.Pip,.r....oa,Nr.)
❑Geodurnnal l leatrne Cooling Rctum l ®Other(explain under k21 Remarks) ft. fL
ft. ft.
4.Date Wrll(s1 Completed: 4-24-24 wig DIP-D-1-25 (ODDS) - i— :,. \ ��,.,., ,
.. ,,..`JL-. - V L�L..•
;a.Weil Location: fL JUN 10 i 2024
Rays Grocery ft. to.
Facile).Ow ncr Nang Facility DV(if applicabkl ft R. • 1 1,rr )gesar4,J
irdred1Wloirf '
•
1674 E. Main St. , Sylva, NC, 28779 R. H. vvvCs14;-:*;
Plnsical Addiess.City.and Zip 21.REMARKS
Jackson DPT INS ITU INJECTION; INTERVALS 7-13'
Count) Parcel Identification No (PMN1
ih.Latitude and Longitude in(kgrccs/minutesrsecnnds or decimal degrees: _,.certification:
;II o.l:ls-.Id now lau Il.ny i.,idlickvli
N W Brian Ewing 5/8/2024
Sigiuture ofCenified Well Coo, r Day:
6.Is tare)the',stills): :. Permanent or )(Temporary Is signing Ihir form.I!hereby certify that the wrlkz)tau!(*err)cottonwood M utroniour
with 154 NC4C 02C.O1(k7 or)5,4 NC.4C 02C.17200 Well Coiolrwstiott Ssv,Jord%and that a
7.Is this a repair to an existing well: ...lies or X NO ropy of this reword has breer prowdr4 no Orr well owner.
if Jbre 1 t o r,')Hlft.flit.nit(tV.A I.Ill.,n»t'w,lion rut.mry:rom um;r,(V0/9 t)w''warner of thr
repair under S21 remarks section or awl the bark of this form. 23.Site diagram or additional well details:
You u1aS use the back of this page to ptAA ids additional well site details or well
IL Number of wells oussIn eted: 13 coustiu do n details. You roan also.teach additional pages if nceessan.
for multrpk IrtjeY too Of emu-wafer auppI,weft,t)y 1 I i,us Mr WNW 1.11,01441441104 ,l,ii I o0
,;thmir, it form. Si iBMITTAL tNSTUCTiONS
9. Dotal well depth below land surface: 13 try,) 24a. For Al Wdha Submit this fans within 1(1 days of completion of well
hor multiple welts!or oil depth,ridtfleren)!example-i%;0Nf and ZEOpNfi conSiflict on 10 the following
10.Static water level below top of casing: (B.) Division of Water Resources,Information Processing I.nit.
if Huh,)chin.OW,r 1 4,10 1617 Mail Service('enter.Raleigh.NC 27699-1617
II.Borehole diameter.2.25" tin.) 24b.For inketlo.Weib ONLY: In addition to sending the form to the address in
2-aabove. also submit a cops of this form within 10 dins of completion of well
12.Well caustruction method: DRIVEN construction to the following.
li e.auger.rotas.cable.dims push;etc i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail'cr,ice Center.Raleigh.NC 27699-1636
•13a l isid IiTm) 4lethnd of test: 24e.For Water Supple A.Injection Welk:
Also submit one sop? of this Mini within to days of completion of
13h-Disinfection type. Amount well construction to the counts health departmentof the county where:
cotustructed
Form GW-1 \n nit('arotuia Lkaisunuuuiu of Em uorurm°aid Natural Resources-Do moo of Water Rmotmes Re,toed.4Lgust 5113