GW1-2023-01794_Well Construction - GW1_20230223

WELL CONSTRUCTION RECORD PorlmerlolUacONLY:
This forincan be used fivt single or muhipl,-,.,'I,.
1.Well Conimetur Information:
14.WAIM
Brian Ewing rMt)51 TO DiSI'RnrtiMi
'.t 1ll l'niecIcIor"..ink fl. H.
4240-B
NC Well Cotmaaor ccrtiflcattoR Nunthcr t5.ftC t_FR C V-ING(For awhi rood weRsi OR LINER Y Yea►k
FROM -----to of IFTF$t "M KNr5S bl%II.%I
SAEDACCO Inc 0 It. 7 r(. 2" ia. SCH-40 PVC
Cau:,:,in "rlic 16.IN%EkC+1slNf,OR7i'BINGdlkalber�
UAgnculturat UmunicilX&PUbliCalcluved-lwwl
rRt)tl 1,.) ' 9� UOUTER rNick.Nrss_ M,rauAL
`_.t4'('ll Cuneuvetim Permit#: _ _ ft.. ft. ia.
list all opph,able well pene,ts(i_e.Coot.Stmir,Variare.ItlaMkirt err.) -
fl. ft. in.
3.Well Use Ielleck well U W I: I ti(NeEN
Water Supply 1Ad1: rrr(iM TO _tit s,tt,tr.m an_l.ns ruuKst,, sttilFRlat.
7 R' 17 rt• 2" ia• O10 3CH-40 PVC
DGleothemal(HealinglCooling Stl)pl%i (:]Residential Water Supple(single)
OhndustriaUCommercial Ultesidenttal Water Supph !shared) -I&GROtrr
FAm}__--- to Mirteltlu_ e.tPLACeMevr+rernoDa (More[
�Im atron 0 ft. 3 n. PORTLAND TREMI
Non-Water Sint)),Well: rt. tL —
50Nlonftonnl; ElRcco%cn'
taJection Wen: n. rL
OAgtiifcr Recharge ❑GroundwiICF Rcnscdi;dion ft.$AND.'ti1Lt,VCL PACK(if ylpNcahk)
/It(IM it) MtrFIf1%1. F:el Pl.tf)'MI'NT MCTN((IID
[)Aquifer Sloragc old Rcemcn ❑Salinity Banner r
ft. 17 A. FILTER SAND # 2
0Aquifer Test ❑Stommater Drainapc
OExpcnmcnial Tcchnolo* ❑Sabsldcncc Control —
UNG LOG imuh additional sllee(ii if nrceswn I
04[kothemtal(C'luscil Loop i ❑Tracer "tom TO 0i'SCRiPTIONIto6r•hm,4tiy.,•.,,m,.,cc1,ir.wp"wr•nr.l
❑Geotlkmtal INt none C'oo Retum) 011ther(explain under#21 Rteou d:s) 0 It. 5 rt. FILL SILT AND SAND
5 (L 15 rL MOIST SILTY SAND
4.Date Well(s)Cumpleled: 2-1-23 Well tDNMW-1 15 rt. 17 h. WET SILTY SAND
a. II.Awatitm: R fL
- _ -
Residential Property
i..,II, 1,•. ., -..;,. Facda>ID#(if applicablc)
1003 Gay St., Henderson, NC, 27536
N. m.
PMski l Address.City.and Zip 21.REMARKS _ Y
Vance BENTONITE SEAL 3 TO 5'
('nanh .. _ ParcelIdLnld,c::aioi,Nu IPINI l
5b.Latitude and Longitude in IkErecs mimrtesisrcnnds nr decimal dtRive(: 22_Certification:
(d well held.ow I:a•lotig I adlict,ui
N W Brian Ewing 2/9/2023
Sigrmttre of Certified Well Cornimlor D i
6.1.1are)the well(s): XPermanent ur Alfempflrary th I herelr rernty that Air wrlN■l bvY(urre)euium ,red m mcordana,r
two*1 SA NCAC 02C AIM or 1 SA NCAC fYIC,D20f1 Well Camer w'rilrt Standards and rhor„
7.Is[Ills a repair to as existtog well: _1Yes or E No c'rIn ai(rh%r record hoc hero pr,witkil to rhr w11 on•arr.
1f"is a repair.fi#out 6rawe wetif c misina rn,a tnfornacaa rt cool r vplamn dw manwe of the
repair fader I2t rmarhr Irmtmn or oar the back of albs form. 23.Site diagram or additional well details:
You nia% use the back of this pate to provide additional well site details or well
ll.Notrber of wells eootorneted: 1 cotlslnlru(n)delaits. Yuu relay alxl attach adlhliolwl pages d'ton t aan-
Fur mabrple mt,< rhm,o nevi-"sae, „cpptr wells ONLY a+Irii the mme n,nstrecn,w you a1m/
sedvnir<>a,r f".nu. SUB1111T'rAL INSTUMONS
9.Totalw ell depth below lanJsnrfam 17 (Ih,l 24a. For AD Well x Submit this form svthln in d:ns of completion of well
h,r r„rrh7plr.01 N,r ell daub,i(drffrrrnr trrarnpk-?{al0tl'awt?@•!)ivn') constmition to(he folbwing-
IU.Static water Iese(below top of call; (ry,l Di)isiun of Water Resources,tformation Processing Lail,
If water kvrl v above tosu%am"+•' 1617 Nltil Se»'ice('eater,Raleigh,N( 2764'/-1617
11,Borehole diameter:8.25" (In) 24b.F@Cjgkallon Well ONLY: In addition to sending the form to dw address in
laaabose. also submit a copy of this form within 10 da1s of compic4son of well
12.Well atnstFvctinn method: BORED constnwiion to Ilea following.
li.e.allgm rt>t;1n.iahlc.dual Iwsh c1c.1
Dhision of Water Resourcm Uo&rVvund Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen•1ce Center.Rakich,NC 276"-1636
132.1'idd IttPnli Mctin,d of feet: _
21c.For Water Suptd)dot Injection Welk:
Also submit one %;op� of this foam within 14) days of completion of
IJb.Disinfection hpe: Amuant; well construction to the counn health depannient of the Conan'wbm
constructed
Form GW-1 Nonh('amhota Ocpanmctit of Ew Ili'lilt LIII and Natural Resourccs-Dn son of Water Resottces Rct tsed.A(glat H111