GW1--05796_Well Construction - GW1_20240926

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can he mod for un;tk or mullipk uclk
I.Well Contractor Information:
14.WATMR ZONES
Brian Ewing PROM TO orctRtrtul
Well Contractor Nark ft. rt.
4240-8 ft. ft.
NC Well Contractor Ccnifirallou Number IS.OUTER CASING for roust-card wcR+l OR LINER(If an Ncatk)
now 1 TO DI;MTTFR TNI('k\rtti MATT.RlAL
SAEDACCO ft. i ft. in.
. y,:nr, N.om Jo.INNER CASING OR TESING rtherteal chnet-late)
PROM TO DIAMETER THICKNESS M.atTRlU
2.Well('or traction Permit N: WI0501142 ft. ft. is. 1
Lisa all applicable'soil permits rt...County.Shoe.variance.*an am, rt.
3.Well Use(check well owl: 17.SCREEN
Water Supply Well: now To evier•ren s1.OTs111 T1110041ds f MAt RRt.
UAgricultunal OMunictpal:Public ft. R. aR
la
❑Geothermal(Healing.Cooling Supply) OResidcnttal Water Supph (single) ft. n'
LIIndustrial+Commcrcial ORcsidennal Water Supph 'dared) I•T
tfRO%IIRGRO nr `III KtU. [NRtsCiMeiT1R1'OOtANOINT
❑lingation tt. I tt.
Non-Water Su1ph Well:
ft. R.
❑Monrtonni ❑Ramon �.
Injection Well: H. ft.
°Aquifer Recharge CI(irotndwatct Rcmcdiaiion I'r.SAND.(.R.+t I.f.I•. C n id*plies*)
FROM LIi; . sl%TEMPO EMPIACTMINT MFTIiOn
°Aquifer Storage and Recovery ❑Salinity Hamer ft. ft.
0Aquifer Test ❑Stommater Dunnage ft. ' ft.
°E'enmcntal Technology ❑Suubsulencc('nraml
°Geothemtal Wheal Loup ❑Tracer 21 BIIRdJNG LOG tat adtadiratal sleets if aecesun 1
p 1 FROM TO altSCR rnoN meter.%amble..,witru k otar.nrfw.tar,eat.)
°Geotltemtal iHeanng('ooling Retuml III/Other Icnplaut under 0.1 Remits) ft. R.
ft ft.
4.Date Wells)Completed: 8-28-24 Welt IDI*A-1 - A-15 (ODDS) * 7�
Sri Well Location: R f L . -- ••—s._�tc ' + i.��i
R. ft.Malcolm Pinkston Property R. R 2. SEP O 2024
FaetlMOnnet Facilie MDN(ifapplicabkl
R. ft.
1915 Chapel Hill Rd., Durham, NC, 27707 R. R. Ift "'r-�`P W r 1
4
w, n�
Ph,meal Address.Cts.and Zip 21.RCMARKs
Durham OPT injection through tooling
(*noun Perccl ilk111111C:1111,1i N.. I PIN 1
Sb.Latitude and Longitude in degreesiminetes/secnndsor decimal degrees: 22.certification:
Of well field,row la67ang It•.,d I L K❑I
N W Brian Ewing 9/11/2024
Sngnaturc of Certified Well Contractor Dare
f,.Is(are j the nelust: Permanent or %Temporary H,.,tgninA Phu tom I hereby to rrtfs that the wilts paa(wrre)eenarrrrr ed it accordance
with I54 NCAC O2C.0100 or I,5A NCAC 02C.0200 Well Construction Ssoakvda and that a
7.Is this a repair to an existing h ell: _]l'es or EN* •..v'of rt.,re.-ord ha,horn prorated to tlar sell owner.
If this is a repot.,fill art brown a rill,,s,Nu.poem Inlorralrs.n oral rt(Iltl/.n the his'.,,'of the
repair ruder Ill remark%.rr,ti.m or vi the bark of Min form. 23.Site diagram or additional well details:
You may use the bock of this page to pros ide additional well site details or well
8.Number of welt constructed: 8 consiniction details. You tnas also attach additional pages if necessary.
For mahlple a(fecrron.a nog—wore,.npph 1 Oh ONLY Math thr same construction ',al,on
srdnar.Nsr Jnrao. SUBMITTAL.INSTUCTIONS
9.Total well depth hellos land surface: 18 (ft) 24a. Fur AU Wells: Subnai this lonn within 311 days of completion of well
for mrhiplr wells h •:Jrpfh,rfdh'renr(r.unrp(r seta r'and'tip 1001 construction to the following
ls.Static water level below ssp of maim (MI D(visietn of Water Resources,Information Processing Unit.
if r'atrr irsrl s above(anaa,um"a" 1617 Mail Service Center.'Weigh,N('27699-1617
I I.Borehole diameter:2.25" Da.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24dabose. also submit a cops of this form within 30 days of completion of well
12,Well eo*atruction nietbed:DRIVEN construction to the following.
tie.auger.rotas,cable.diced mask Mel
Division of Water Resources,Undergramd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail sera ice(voter,Raleigh.N( 27h99-1636
13a Yield N pnul I4e.For Water Suppls .k.Injection Wells:
Metimd of teat:_--
— — Also submit one copy of this fonn %Ohm to day s of completion of
I3h.Disinfection h pea Amount well construction to the county health dctinment of the coat where
constructed
FormGW-1 North Catalina t).pantnem of Err 110111111.1111 and Natural Resources tHsnion of Water Reaaea RC%tied August Sill