GW1--03875_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD ✓1/ For!menial Use ONLY:
flu form can be used for sinek or multiple„ells �°
1.Well Contractor Information: \--
\. I 14.WATER ZONi S
Brian Ewing I! "MOM TQ DLS('*IPt'1O%
Well Contractor None ft. 11
4240-B ft. ft.
NC Well Contractor Certification Number j 15.OUTER CASING(for muMi-cased oelsi OR LINER ill ap hcabk)
01110M TO Dt4MrTrR TIOCK"FS4 MATTIOAI ,
SAEDACCO fl. n. to.
Cancan)Name L le.INNER CASING OR PULING urthermal closed:)
FROM TO ? DLS.METER THIC'k Cs4 MAiEarAL
2.Well Construction Permit M: j 0 It. 10 n. i 2 11. SCR-40 PVC
List all applicable well permits Re.Counts Stale.Variance 1/('ecbon rlr.t 4• - .
R. II. it,
3.Well Use(check well sae): -
r_r(Rsa::.
W r Well: sit-_. -- --_n11.1IFTI H ...1 tit‘I/i - 1114 kSl'.% M'.TF"RIar. '
Di46riculmral DMunicipa6'PI►bhc 10 ft. 20 ft. 2 .0 .010 SCH-40 I PVC
msal(Heating/CoolingSft. 11, ia.
OGeothe apply) OResidential Water Supply(single)
I Ilndustria1lComnrereial DResidential Water Supply(shared/ 2t' � - f. —
IROM i TO , NI(1 F HIM. - F.Nrl_(l f MEiT MElil00 a AMOUNT
❑lm atton R. n.
Non-Water Supply Well: R. R.
ElMonitonne ❑Recovery --;
Injection Well: n- ft.
OAquifer Recharge f-JGroilndwatcr Rcmcdiation 119.SANDK;RAVEL Mel((i applicable)
' TROM j TO St Sri RIf1, EMPMA(T.MEVT Mr71"Fr(1n
❑Aquifer Storage and Recosety ❑Salinity Barrier 8 ft. i 20 A. FILTER SAND 11 2
❑Aquifer Test ❑SiormwaterDra►nage ft, i (t,
❑Experimcnlal To:hnology ❑Snbsidcrtcc Comm! t
M DRILLING LOG(attach additional sheets if aecessan)
❑Geothetnwl(Closed Loup, ❑Tracer /ROM 10 OTSCRIPTION4inl.r,harem•..,.11lOntlirapt.ow*slowe(r.l
❑Gcolhetmal IHeannk•Cooline Return) ❑(Alter(explain under el Renaults) 0 ft. 5 ft. FILL SILT AND SAND
5 ft. 15 ft. SILT CLAY MOIST
4.Date Well(s1 Completed: 5-6-24 Well IDIOT/ell-4 15 ft. 20 i. SILT CLAY MOIST TO WET
5s.Well Location: O. ft. . ..R' {
s t-r t•..: b L../Gaston Refuse Disposal 14 rt.
FaclLts f_h,ncr Nantc 1:elm ID.e iif applicable) �1�f
ft, ft, U2 8 2024
250 Porch Dr. , Gaston, NC, 27832 ft. rl.
Pln steal Address.City.and Zip -
11.REMAKESlYris.,'s ICE
Northampton BENTONITE SEAL 6 TO 8'
(Taub) Pan:el Identification No MINI
5h.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(d„cl:lwW our l:u nogg lz sitinCierd)
N W Brian �Ewi�ng . 5/17/2024
Signature
6.lo(are)the wells) ❑Permanent or NTemporan gr-signing ihu horn.1 hereby certify ohm the welh'sl two(here)artartrurted in oceondmeir
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Cantrucflon Sktafards and that u
7.Is this a repair a as existing well: ❑Yes or ®No corn of this woof has been provided to she well owner.
If this is a repair,fill out kn.me Keit,"mina teem information awl r rplulit rile nature of flue
repair murder 121 remark.,section or on the hock of ilia,form. 23.Site diagram or additional w ell details:
You mas use the back of this page to provide additional well site details or well
8.Number of wells committed: 1 construction details. You may also attach additional pages if necessary.
For nsalripk mjecrk rl of non-wows tappet wells ONLY wan Or site construction on.,to.
submit OM frmao. SIJBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 (h,) 24a. For All Well Submit this form within 3(1 days of completion of well
For multiple wells list all depths if different teranmple-30201/'and 20 1001 constniction to the following-
II.Static water level below top of easing: (ft.1 Division of Water Resources,Information Processing Unit.
lr,r,,,t h r1 r ,i.,,,,, •.,,,; , . _ 1617 Mail Service('cuter,Raleigh,NC 27699-1617
11.Borehole diameter:8.25' 00 2-lb.Fur Inketion Welly ONLY: in addition to sending the form to the address in
24a abuse. also submit a cops of this form within 30 days of completion of well
12.Well coustrimion nw-thnd: BORED :,mstructtun to the following
tic.auger.ratan.cable.direct push.etc I
Di,ision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Semite Center.Raleigh.NC 27699.1636
l3a field 11C1am1 Method attest: 24c.For Water Suppl, S.Injection Wells:
Also submit one cop, of this turn „Ohio 30 days of completion of
I Jb.Disinfection t Amount: well constnrction to the count health department of the cotton where
constructed
Form GW-t North Carolina lkpanrnlcnr of Ens ointment and Natural Resources-Do Etna of Water Resource Re.Iced August NI