GW1-2023-01924_Well Construction - GW1_20230222

WELL.CONSTRUCTION RECORD 1:
- \, \ Far Internal tJsc ONLY:.
This forth cam be used fei single at mnitipk)ssUs ^ _ v L
�` 1.Wc11.Contrnctoli�[teforn;tatian: � _ ,
'14.1VATEPMON ES j l
Brian Ewing FRONT Tta I MCREMON
Welt Cnrnrador 1 talr:l4r R. fr.
4240-B ft. ft:
NC Well CommctorCcriffi tionNuwbcr `13:'OU[ERCASiNG`irde*&ulii=used-wr HO'ORLiNER't1CJi
FROST To nIMMEMM TfInCAM—S5 MATERIAL
SAEDACCO Inc 0 t4 7 tL 2" I I hL SCH-40 PVC
(entp;ura IVamr. 'kMANNER CASING ORTfrBINGa{s i ttietiubi ebu iJ too' :.u` :a.:-.
FROM TO DEMME ER - TFHCKNESS'i MATERIAL
2:Well Cgntsttpciitin Per a»t?: R, R. 1'
LWtilt appgnF 61e well p6*4 0r.County.S1w,n,:trariarsr.lga:dcn
-ft. tt: iie
3.Yl'cil I sc{chrxl:��e11 use}; iI7:St:ItEEN .
Witter Supply'Vilelb - FROM- I TO I WAURTFA I $T.OTSIZs. I TJnCKNtZS I MATERrrlt,
CIASricultittal 0Mt'hiicipal ttb;ic 7 ft, 17 ft. 21, io 010 SCH-40 PVC
1300themntl(HeatinglCooling Supply) ®Residential Water Supply(single) ft. ft, i n,
13hidustriaYConmtcrcial 011csidential Walct.Supply(sixtred) ^19.GROUT',-.-:
FRONT TO. SATERIAL" FN11FIX0,10T;U HOD&,1L1IO[1,W
t9lrti Htion 0 'ft.: 3 ft. PORTIiAND TREMI.
Non~Yates Supply Well:
ft. ff,
ftsltv4unifi9dng o tr owly
Injection WL[t: ft. EL
CiAquifct ltccdarS Clrivt�Iidt4atcr Itcincsli;itiou :1srs r<ntltTctt ve[PACK ji('A,rt;cAbtif.
-61Rg51 1To 1fA'rl?R1AlT. kSIP1,ACEHF:NT?416-tRou -
t7Atj11ifcr.Stairtgc:ttxlltcC[i>sty t�Sc7lliilty 13atricr' 5 R'. 17 ft. FILTER SAND # 2
QAgTeifer7m;st on,Image fG fG I'•
I]>ripwiniculalTcchnotogy f3S+sb.j!ctcaccC'oidmi ^ '
1 :t13DRIC[.1Nq;'[:OGYatt�chadditioit:tl 5cefslf:Rrec`s�iti•)`
t7Ciodremyil FRONT To 1105CRter14Ntwbr. jx:' n mesa)
l7Goothenual(HeatillflCaollna-Mum) Elodle.(explain under#21 Rotas s) 0 f4 5 ti FILL SILT AND SAND
5 ft.. 10 ft. MOIST iSILTY SAND
4.DB ~Veil{S)G]glpleted: 2-2-23 fYelt 1Di1MN'1 10 it. 17 fL WET SILTY SAND
54; YL11
Pugh's Auto Sales
Faciliiy,On ncrNaruo Factdity 1bg(,Eappiicable), R. ft. tD AF2
609' S. King St., •Wi.ndsor, NC, 27983 fL: tL
Plr}si:nl.AildT5S--'it} andZi ItTi rflz3,s•C 1 ,�rTra�, c� t ;
- - P `24 REMARW
Ber tie 'BENTONITE 'SEAL 3 TO 51,i
('Orirtt}• - 1'�rrC71ct0utiE'i�,�liquNp;(9�L11} P
5b..r otund*and t`�td,9reC L 01"l."aifiiia dcgtCcslminutcslsccnnds tir.dca im tl llcgrtxs: 27.Certification:
(ifi�Cn is S:JliCicrd) -
N W 1dam .Ewing 2/10/2023
SigmlurvofCtrti6edPlcllCo»uaetoi'IV. Daic
6.Ira(:Ire)thz''svell(�)t MFP rtu went or riTemporury
by.4gnfng lkly faim.,l Arrrby vr(rifF fhdr 1hr,iefifs!vies(asrr J ctny7rvc1erl ur occ'urrrrncr
with 15,t,YCAG 01C.OIttn rim t5d lsrG,dC A3C A2gt711'eil Cotrstricrlrur Stan!far�fs end rlurreT
7.LS tltiya reliaii•fu ad cAstin Nnelly Mee tir jaNu caprofrhJs iecrirrihr sixen nrmirlcd r`oihr aril mrnrr.
Tf rtl�S.lY R tY}kTIP.f)ll f�+r firtvnm well rarmruetl,xt 1lrfarrnRrlon aTRrl e�pinbt d:o rutmre.,f the �j
rtilu:ir tauter p2!remadLs srctian or on flee bar-•of rfih fornc 23.Site diAgram or..,additional well detriits:
Yon tiro} usg[tie bac6 of this urge(a pro,,do additional well site details�or)~'ell
S.Nutuberbf wells mroRstructed: 1 cousutiction details: You inay.tlsa attacIiadtlitlol�el if>i�cess itp.
For inalalJrle trt(e�ih7n arRat:-rrwrer nrppJl•urTJs�D,YLY u'trh dru.smap cuastrurrr"ar,y'cu ntrt I •
=6111itwie form. SUBMUTAI:iNS1 ['PIONS.':
9:'1WA Well do tit belcr r land tatrface. 17
.p {11P.} 2�f:e. Par�1t1 lYellsi Gnhlidl Ilris'fnmt within 30 tiups of coTmptction of well
Formidrlplelvell.0istal1d.Trkyifdifferedr(e.mwok+-3@200'aiP12@IM) eonsinrction'to the folloniu-
i
10.Static wetter level below top of¢trsitt„ ((1,) un'essun of Water RLr'aurce3.Infirrmation Frpce�sin2 unit,'
Tfmu�r t:ve71s irLavu eus6a ivc"t" I617.Alait S6Tice railer,ILde:iO4-xis 27699-I617
It.i3orehole diamcter:8.25 00 24b.ror btj t tr1 Wells mNLVY in addition to seading.the form to the address in
246 awn also subtuit a-.copy of this fonit within 30 days of completion of twlI
12.Nell coustMetion method:BORED Lotisimction ro the Iollowflie:
(i.e.aq;.to",cable.dim:}Frrsk
)nivisfon of Water.116ources,Pudergr•uund tojectlan Control Program,
FOR WATER SUPPLY WELIS ONLY-' 1636 hLtit Scr'vice[Center.Raleigh.NC 27699=1636
f3:n'Yic]d( tm) hTctlrgdctFtest: ''te-TorV1'atcrSuttvly_&[ui-"t uWeMs:.
Also submit oils c6p}' of lidsfonri within"sli days ofcotvpletion.of
13b.Disinfection"'pc _ Amnuat• )vcll consinlcdon to the county iie,,Ith department of the-coin"'where
contsmictcd.
Fomi G%V-t Nonh Carolina fltiprtRmcnt.of ETn'ituruticto and o Iatural Resources Revised August2013
it