GW1--05841_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD For InicraelUscONLY:
Tim form can h-uxd few single or mullipk ncd.Is
1.Well Contractor Information:
II.WATER ZONES
Brian Ewing FROM to j DEM RI►tioN
Wdl Comtackx Name rt. tt,
4240-B rt. n, - -
NC Wdl Contractor Certification Nastier 13.OUTER CASING(for muMi-ea+rd ocNo OR LINF'R(Y a calk) i
MOM TO IHAMITFR TNlr l\I\N NI%TTN!kl
SAEDACCO rL n. iii.
Common y Name U.INNER CASING OR Tl.'a1NG usothe.wal dined-lump)
PROM ' TO DIAMETER ' TlIKkN Ess I%WOII
2,Well Construction Permit 0: 0 ft. 13 It, 1 ie. SCH-40 PVC
List all appli,able%ellprneiu(i-r.Cr,wuo.Sane,Variaere,b 6 tar.) --.
ft. n. in.
3.Well Use(check well use): 17.SCREtN
Water Supply Well: FROM TO DIAMETT:M c1.0I btii Tau/k\t\. NN1 FAR Nt.
❑Agricultural OMunicipatiPublic 13 ft. 23 ft. 1 his .010 SCH 40 PVC
DGeotberrnal INealing,Cooling Supply) DResidctnial Water Supply(single) ft. It. Ia.
Dhtdustri.•Q:Commercial DResidrtutal Water Supply(shared) 1i'Ga°QT
PROM TO MATERIAL EMPLACEMENT 5(111100 4 AMOUNT
❑Rngntion ft. rt.
Non-Water Supply-Well: n,
n.
It Monitoring ❑Rccosrn'
Injection Well: n• n.
CI Aquifer Recharge CIGronndwatcr Reniedialion IT,SANDK:RAVEL PACK Of ap/re(ile)
MOM I To MATERIAI. FMPIAl-FMF\T Million
❑Aquifer Storage and Recovery ❑Salinity Ramer 11 ft. 23 n. FILTER SAND * 2
❑Aquifer Tcst OStomm:oer Drainage ? —
fL 1 ft.
❑Expcnntcntal Technology ❑Sidbsidcncc Control
26.DRILUNG LOG(attest additional sbrdc if occr can 1
OGeotlwrinul(Closed Loop) ❑Tracet PROM TO , DFM RtPT1fl' .61-,hatJnc«,..duns,Not,xrw:r•el.I
OGeodientai IFleatingC'oolimg Returnt ❑Oilier(explain under au21 Reuadm) 0 n. 5 ft TILL SILT AND SAND
5 ft. 15 ft, SILT CLAY MOIST
4.Date Waits Completed: 9-4-24 Well 1DMTMW-1 15 ft. 23 fL SILT CLAY MOIST TO WET
5a.W ,°�
Well Location: ft. n r'�` • V.7'...W
L.i.A♦..r : A{/ 1....
Fuquay-Varina Elementary School ft, ft,
Faetlit,ale net NOM Facility IDatilapplicable) ft. ft ' OCT d 1 2024
6600 Johnson Pond Rd., Fuquay-Varina, NC, 27526 R. R. in. ,,,,,.,_ ,r rr .1 1
Pan sicd ildiress.City.and zip 21,mums -
Wake Temporary well for grab groundwater sample
I,.ai,.. PmclId.aldlCattofNo IPtNi
Sb.Latitude and longitude in degres,loinutes:seconds or decimal divers: 22.CMiBealini:
Of Mall field,tar lai Tong is sidthkw1
N W Brian Ewing 9/12/2024
Signature of Certified Well Contractor Dote
6.Is fare)the wdlls): :JPennanent ur XITemporan ,y
it,signing rho form,1 herein certify that the welts'$t ae(Moir)to'mrrae'rrd irr IXcorvi m(r'
with 154 NCAC O2C.01(10 or 15A NCAC(12C'.0200 Well Conatmrhiur 5arrahtrd.end rho:as
7.Ise this a repair to an existrag well: Lilies or IL NIi ruse of thin record has kern pno 4..d to the aril aligner.
!f rlis It or repair.fill mil Ammo+kelt,,nurera hem rejorrrrereun Wm/r tphurt Thy earns Of rlie
repairarrrfrr 421 reamers.,sr.teem of„rr the haft of this form 23.Site diagram or Additional well details:
You Mat use die back of this page to pros ode additional well site details or well
it.Number of wells amstructed: 1 cotutmdion details. You may also attach additional pages if tleeessan.
for ma zepk rnjr<tries or ton-nacre urpplt wells ONLY wrth Mr sew ctwch•urtitw ,e:u,no
Auhmir one IS-,rm. SUBMITTAL QISTUCTIONS
9.Total well depth below land surface. 23 (fie,) 24a. For All Wells: Submit this font within 30 dais of compkiiou of well
far esehtpk writs!in pll depths rl drfi'rrnr lrrompfe- 4'2'00'pod 14-5 MO) constmctian to the following
le.Stalk water level helms top of casing: (ry,) Division of Water Resources,Information Processing l nit.
1f nn:re lr,r!n I,.M.,r.,,,to,; 0, . 1617 Mail Service Center,Rakigh,NC 27699-1617
I I.Borehole diameter 2.25" fin.) 2-lb.for Inkxtion W'elb ONI,ti: In addition to sending the form to the address in
24aabose. also subunit a copy of this form within 30 days of completion of sell
12.Well rna_ctrwction method: DRIVEN coasttucuun to the following.
u e.auger.rear..cable.direct push etc r
Dhision of Water Resources.Underground Micelles Control Program,
FOR N1'ATFR SUPPLY W FI.LS ONLY: 1636 Mail Service Center.Raleigh.NC'27699-1636
I3a Yield I>pmi Method of 24e.For Water Semis&!niceties Welts:
Also submit one copy of(his fonn within 3u dassof completion of
Iib.Disinfection type: Amount: well construction to the county health dcpanntent of the county whore
— constructed
Form GW-I Nonh Carot/aa Ik.4sinnrni of Ent uoruiriu and Natural Resources-Disauos of Wald Rearms Re.teed.kugtat NI t