GW1--04674_Well Construction - GW1_20230721

• WELL.CONSTRUC'1'.ION RECORD For Internal U ONLY:
Tlii7 fortn can be'uscd rot singleot multiple wells'
1.Wd1.Cmltraetur Information:
IT..WATER.ZONES , . . -
Brian Ewing FtU)I TO DESCRIPTION '
• Well COniRCtor h;ttnc R. ft. I .
9240-B ft. It.
I. l
NC Well Con taclorCeii cation MotherI'`IS...OUJTERRCASiNG dorStiulti-rrvcih ctlsl'OR LINER:Kan-tiesibk)'•. __ . I
I Frtovl I To DIAMETER Ttrict;NEss SIAn:nIA1.
SAEDACCO Inc ft. I ft.-
f I Is.
(:ookliany Name 16:•IN\ER CASING'OR,TUBING-gSencrernial cfueddool!E;- . •
-
FROM TO DFAMF.TER , THICKNESS MATERIAL
2.Wdl Consttlrction Permit II: 0 ft. 28. ft. 1 'III- SCH-40 PVC
1.iit all Glprlic•rbre wellpeneis(Le:County.SlGae,Variarre,fiyerrierl etc.) :h. fa. in
. 3.Wclt ijse(chcele well use): • .17:SCREEN .
Water Supply Well: FROM TO nlArEtisrt sr.OTS173: THICKNESS i MATERIAL
°Agricultural . tJMtinicipalfPublic 28 ft. 38 ft: 1 is .010 SCH-90 PVC
©Geothemrat(Hcating(Cooling'Suppty)' .DResidential-Wafer Supply(single) (i. ft; im
DludustriallCoamtcrcial ®Residential Water-Suppl} (shared) IN:GROUT, : _.. ._
PROM TO. MATERCAL EMPLACDIEST METHOD CA,MOUNT
°irrigation ft. • ft.
Nqu=Water Supply Welt: ft. fr. . , . . .•
16MPnitoring • °Recovery - _ .. ,
Injecflan Wei: ft. . ft.
CI Aquifer Recharge OGrowniistaicrRciucdiation -I9:SANBiGRAVEL-►ACt;uruigilli2nte:' •
-FROM To MATERIAL KM PIACtM I:NT HE:TIIOD
[]Aquifer Storagc,and Recovery °Salinity fairicr 26 R. 38 II. FILTER SAND # 2 •
°Aquifer Test. ❑Storiwatcrl}rgirii c ft.. ft.
13E:grctin►cn1n1 TcehnoCoov pSttbsidcncc Cgitiru►L -2n;DRILLING'LOG7allach•addilioital shcetiif ircc ssstrvl- - • - - •
OGeclthennal(Closed Loop) °Tracer I FROM ' TO DESCRIPTION(color.hanlnca,si,RA'nick Ow.rein ssn.vial
❑Geaatlteintal(FleatineICuoling Return) °Other(explain under.#21 Retaad s) 0 .ft. 10 ft, FILL SILT AND SAND
10 ft. 20 ft. MOIST SILTY SAND
.4.Date Well(s)Completed: 6-23-23 'Well ID TMW-2 20 ft, 38 ft. SILTY SAND MOIST TO WET CLAY
5a.Well l creation .ft. ft. -
Auto Truck Transport USA ft.. ft. L C E 62 V_D
FacilHy.CiwocrNamc Facility ID!!(iIappliablc) R. ft. .11JEL 911
320 Bear Poplar Rd., Cleveland,.NC, 27013 . ft. . ft. " 1 Z�Z3
Pln s9cul-Aildtvss,City.and Zip .1 I;.RKMARfis' litfut z: Cil Prf..cuirrep,1 U
Rowan BENTONITE SEAL 24 TO 26' CPWQMOG
(:ouuly Pared hte n ficarioai No,(PiN)
Sh.ll atitude and t.ringrtude in dcgreeslminutcslsecOnds or dcchiral degrees: 22,certification
(il1,1cll new,one'along l;rssdlicr_rd)
• •
N `� - • Brian Ewing 6/29/2023
• . Sigmtur:.of Certified Well Contractor - Date
6.is(are)IIIC vte11(S):,OPefTnarlene or %ITentporary !(p signing this famr,.l Irerebr t•errifv Mat the halts)war fiarreJ ean-trrvcred iir.aticarrlancr
OM 1 fa NGlC OTC.0r00 or LTA NCetC 02C.0200 Well Constrict ra Sroa4ards and floe(a
7.Is this a reliair to as existing well:• Oyes or ISI No -ropy ofdri.r ceases bar Scot pmenlc4 to the cn-7l owner,
If rhls:h o ipa r.fell oat(tw1t t well eomrrucrbta brfgraiedcm and r tp(abt the(sure of the
repair soder 1121 rerearks'secliun al-octet the hark of(Airfare,. 23.Sitediagram or additional well details:
You may,use the back of this igige'to.provide additional well site details or well.
8.Number of wells constructed: 1 • collstiuction details. You may also attach additional pages if tiecessal.
For nullrlp/e itdecrlinr oriw/t-leatt-r tnpply a'e((e ONLY with rhiasamT co,rstraefiwr,yas con
s:unnirGee fare. SUDNIITTAL iNSTt_rCTiONS
9.Total welt depth below land stirface: 38 (ft.). 24a..For All Wells: Submit this loan within 3U.days of completion of well
For malrlplc ierlls list all dcprhs ifd1�,Pivrnr i.rompft•-3@2Pir and.20100) construction to the following:
IU.Static water level below top of easing: (ft) Division of Water Resources,Information Processing Unit,
lfwale,level lr above ens*,rue••+" • I617,1Hail Service Center,Raleigh,NC 27699-1617
I1,Borehole diameter:2.25" (in.) • 2.11b.for itrikction Welts ONLY: 'In addition to sending.the form lei the address in
2,14 above_also submit a copy of'this form within 30 days of completion of well
12.Well construction method: -DRIVEN coilstnietlon to the fellowine:--
(i.e.Gager,rotary.cable_aired push.etc.) . 1
. Division of Water Resources;Uudergrouted irujeetion Control,Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Malt Service Center,Raleigh.NC 27699-1636
13 'Yield Method of test: 24c_For Water Supply&Injection Wells: •
a �6►m) Also submit one•copy of this form Within .0 days ofcompletiotiof
13b.Disinfection type: Amount:' well construction to the county health department of the county where
- constnictcd, i
Fartu GW-t Nonh Carolina De-panm nt of Environment and Natun•i Resources-Dh'islou of Water ft!c.iircm Revised Atgut,32013