GW1--05840_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD For Internet Use ONLY:
This form con tx nccd frr sinpk or multiple actis
1.Well Contractor Information:
Brian EwingS.W /RR ZONES
MOM to iW 4 KIP!Ill\
Well Contractor Nano ft. ft.
4240-B R. ft.
NC Well Contractor Ccniftcatton Nunt sea IS.OUTER CASING(tor awki-csa rl cads[OR LINER tit ap lieshk)
PROM TO DIAMVTtn Trrxxtsc 14.i1TRtAt
SAEDACCO R. ft. is.
Compcutl Name If.INNER CASING OR TUBING ltisIharmaleleed )PROM To DIAMETER THICKNESS %l%MtUUAL ..__._._.-
2.Well CDnairsetion Perledlt N: 0 R. 11 R. 1 l•. SCE-40 PVC
Lilt all applicable well permits(Le.County.Slate,Variance.fIYati,ml err.1 R. R. l .
3.Well I'oe(check well use): 117.SCREW
Water Supply Well: PROM TO DsstrtrR 'StOTSIM Ilittwatem I Mal-Pa141.
LIAgnctdlural OMnnic ipal;Public 11 ft. 21 f1 1 in 010 $l:B-4U PVC
OGeothetmal IHeating.Cooling Supply) OResidennal Water Supply(single) R ft. is
Ohtdustrial/Comnlercial OResidential Water Supply(shored) I OMWOT To MATERIAL EMPLACEMENT ENT ME•twon a AMOUNT
❑Irrigation ft. A.
Nom-Water Supply Well: ,
ID hfonitonns ❑Recover ._
Injection Well: n. ' II.
❑Aquifer Recharge ❑Croundnaier Rentediarion Ip.S.'ND(.R(y VI.P.4('K(Ifapplicable)
0 Aquifer Storage aldRecoyer ❑Sal inity Banner PROM i ! MATERIAL tMW.ArYMINrMITp([n
13 h. 25 ft. FILTER SAND 4 2
IAquifer Tcsl ❑Stommater IAainigc
❑I:xpcnmcntal Technology ❑Sithsid etsx Comm! ft. ft
OR II I I NG LOG(
❑Cxrodlemtal(Closed Lout ❑Tracer EIS OW .Mkiwrl sheets if oecc,.ars I
p PRoyt TO DESCRIPTION 1tolor,Leman..,,.irn,.I.npp,granen.ete.l
❑Geothemlal(Heating/Cooling Return) OOther texplam under P21 Retealts) a R. 5 ft FILL SILT AND SAND
5 R. 15 ft SILT CLAY MOIST
4.Date Well(st Completed: 9-4-24 Well IRO TMW-3 15 ft, 21 it. SILT CLAY MOIST TO WET
Sa Well Location: ft.ft. Z.s.-. `- ._. . iiii L,„,
Fuquay-Varina Elementary School R. A. OCT it 1)024
Fscility,'Ow ter Name Teeth's ID"(if applicabkl ..• ft. n,
6600 Johnson Pond Rd., Fuquay-Varina, NC, 27526 R, ft It,%...1rca.l w r •y ,--.2 t
Plnsical address.Ctn.and Zip 2l.REMARKS ''a
Wake Temporary well set for grab groundwater sample
1..i a 1'• Parcel ldc,ui,fs,Iir.i,Ne I PIN
5b.I.;itinuir and l.nnginulc its rktree.:nrinutev'meenndy nr decimal desires: 22.('ertiftcatiita:
ill u.I .:1 r. I.,Ir.IK_Is�n1licie.11
N W Brian Ewing 9/12/2024
Si;ruturc of Certified Well Contractor Dote
U.V tare)the wdlls): DPrrmanent or ETemprrran ft,wean,;lair Dims.I herein'certify rare the wr1Nnl tint Orrrrl,rrnrrn,cted in arrordalrr
wiNl 154 NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Corwrwr star Sassdarris wind rho:a,
7.Is this a repair to an existing well: Jl'ea or E No r.rpr of rhi,retard has hrrn prm•ulrrl WA.-urn rm•nrr.
4,h1,„o repotr.(ill rot*mom well a<wulnn etas[turiurrurrr,an and expluln the moire r4`rhr
o iordrr P21 remarl.%.,r.lirn,Of OR the bare or this form. 23.Site diagram or additional well[Mails:
You may use the back of this page to pros ode additional well site details or well
S.Number of wells onastrocted: 1 cotultucaim'details. You may also anaelt additional pages of ins essan.
For maltrptr at),-ron t,r 01N1.101 rr Nipph We&ONLY wort rhr same nwra r woliav tttl,r,n1
uabniirone form. StIBMITTAL INSTUCTIONS
9.Toad well depth below lard surface: 21 (fl.) 21a. For All Wells: Submit this fort within io days of completion of well
For malnp*wilts list rIll,deprbr ifddjl`errnr k'rmnplr•30100'mld 2@'100'1 construction to the following'
1R.Static water In-el below top of casing: (ft,) Division of Water Resources,Information Processing l nit.
ifwruer keel n abort caswx.ow'a 1617 Mail Service(cater,Raleigh,NC 27699-1617
II.Borehole diameter:2.25" tin.) 246.For Irketi.a W'cllt ONLY: In addition to sending the form to the address in
24a above. also submit a copy of this form within so days of completion of well
12.Well COIDITRctlon method: DRIVEN ernUttudion to the follow log.
tic.anger.mists.cable.dims push etc I
Division of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sets ice Cemer,.Raleigh.NC 2 76 99-1 636
13a Yield 1 24c.For Water suppls &Injection Wells
Rpu) Method of teat: Also submit one .opt of this form within to darsof completion of
131._Disinfection type: Amount: well consuuction to the colonyhealth deportment of the comma.where
constructed
Form C,W-1 North Carolina['gunmen'of Em n siumiu and Natural Resources-Dnanon of Nani Rimairres Ras Iced August H'•I I