GW1--04675_Well Construction - GW1_20230721

WELL.CONSTRUCTION RECORD Far Internal UscONLY: '
Thin faun can be used for single or multiple wells•
I.Well.Contrrtetor Information:
tL:\YATLRZONFS . . -
Brian Ewing FROM 'TO , bw•_SCRIPryf1N
lVcll CaMQICtpt Hanle
fl. ft. '
4240-B ft. ft:
NC Weil Contractor Certification Nutrbcr '=tS Ot1TERCASING(furmutti=cisrdnellskORLINERlitap tfcabk)'. . .
, most To DIAMETER • TIDCK-NESS MATERIAL
SAEDACCO Inc ft. H. in
Company N m . t6:1NNER.CASINGORTURINGi eutbeirti:ttcDused-toop)•.' '
FROM TO DIAMETER THICKNESS -MATE•RIAL
2.Wdl Consttuct60111 P.cvmit#: 0 It, 25 ft. 1 41• SCH-40 PVC
List utl applicable writ printitr(Le.County.Swo.li'srirnce,fr' SCi4.ic.1 It. ft. is
3.Well Use(Cheek well nsc).: -17:SCREEN .
.Water Supply Well: FROM I TO UttMFTFrt slOTSrri TRICKNEss 1 MATERIAL.
El Agricultural iJl4Rlnicipal/PU.tic" 25 ft. 35 ft." 1 Ia. O10 SCH-40 PVC
DGeetlu:mnat(icatinglCooling'Supply) ElResidential Water Supply(single) fi. it: nr,
©industrial/Conlntcrcinl ©Residential Water.Suppiy(steered") tBzGROUT. ._ _ . . . • .. . ..
FROM To. MATEROL I ENIPLACEMOT METHOD l AMOUNT
❑Irripitian ft. rt. •
. Nou4Sater Supply Well: • 7t. R, •
6dManitoring DRct:m-et} -- .-_
Injection Well: ft. ft. I
❑AquiferRccharge DGroundwalC"Rcincdiation -19iSANDx;RAVEc.PACR iratgtuearrtef= " - - - -
"E'RONI .TO r MATERIAL EMPLAC.t Ho:NT siETnnn
❑A+iuifcrStoragc,and Rccovciv "❑Salinity Hairier 23 R. 35 ft. FILTER SAND # 2
El Aquifer Test- IJStorrriwatcr Drainage
ft. (t.-
1:11=VetittlCRi71 Technology DSnhsidcbce Control -1a.fRnLLUNG'LOG7attaeh additional sheds if rice.ccarc- . '
OGeochermal(Closed Luup) DTr cer FROM TO • PF5CRWPT1ON(tour.hardnco,stata,nls h Lsc.:rrrin site.clal
❑Geotlteitual(leatinelCaolittg Return) ❑Outer(explain under#2 I Retunths) 0 .ft. 10 ft. FILL SILT AND SAND
10 It. 20 ft. MOIST SILTY SAND
4.Date,Well(s)"Completed: 6-23-23 'Well 1110f TMW-1• 20 It; 35 ft. SILTY SAND MOIST TO WET CLAY
Sa:Well Location: .rt. ft.
Auto Truck Transport USA fL It, g"" C gr
Factlity;Ow•ncrNaloc Facility!I)I(i(appli:able) ft ft. 6.i��..t ti�/ �'
320 Bear Poplar Rd., Cleveland, NC, 27013 , ft. ft. JUL 2 1 2OL3
Pltysr-a1 Address,City'..andZip ,21.REfLARICS• . . . ,• '
Rowan BENTONITE SEAL 21 TO 23' Iflttrlmidt'-fl)ire catmaZg URI
Ce
Cowrytared kt_uliaruionNo,(PIN) J` J�
Sh.I.iititude and"1.ongituzde hi deg ecs/minutcs/seconds or decitnal degrees.: 22.Certification:
(Ito ell Feld.ene lat,louui;srdiieleni)
e
]ii' W Brian E in 6/29/2023
SigmWrufCertifiedWell Cantrnctor' '� • Date
(/.Is(are)(he R'elt(s):"❑Pernlauent .or 11Temporary tty aigninx this fasm,-i,rereb,certify thcr the erri1(.0 recta Owtr)cwr.i urted In ocrorstancu
with 15,t,YCAC 02C.010'.I or 154 NGtC 02G;n20o 11 eff Courrirtraen Standards and that a
7.Ls this areliaii-tuaneaiistingwell: ❑Yes Or KIND ropyofriririeci d Iii4 berm(in-widedr?rriteorlltnerit•r,
/f this II reptiIlr,fill q4r kioiwt weft ecairmo ro In aroatkn tail t xpladn the nerare of the
repair raider 1121 remarks'section or wi the hart`of this foray. 23:Site Diagram or additional well details:
Yea May use the bath of this page to provide additiouat well site details:or Well
S.Nutuberof Wells Coast meted: 1 • • cotistmctioti details. You may utsit attach additional pages if ticcessuly.
Forrnalrlplc irtfectlnn orarnt-rr'crrer snpph'wefts ONLY trick rhrsameconstrlwg on,ytut Curl
salmi,one form. - - SUBMITTAL iNSTCTCTIONS
9.Total Welt depth(teloiw land stit1 ice: • 35 (ft.) 241a. Fur All Wells: Submit this foot within 30 days'of comptetion of well
For rrnllrip*P ietra list RIl depths ifdificrt'trt tesamp(r-1@ tk1•ar.V1:2@ 10n•) constriction to the Cottoning:
W.Static water let'et(tclaw top a6 easing: - (ib,) liAINiuu of Water Rcvciurc s,Information Prlicessing Unit,
if moat kid is abort'['Win.Mt''•}" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:2.25 (in.) tab.For rill-wino Wells ONLY: in addition to sending tlx:form to the address in
24a above. also submit a.copy of this foiui within 30'days-of completion of Will
12.Well construction Ruehod:DRIVEN coustmctlou to the folloa°iner '
fix.auger,rotary,cable.direct push etc.}
D6vislou of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:' 1636 Mail Service Critter.Raleigh.NC 27699-1636
83rt;Yield Wu) Method of test' 2 do For Water Supply.4c injection Welts:
Also submit one copy of this Irani Within 30.days of completion of
13b.Disinfection type: Amount: well constniction to the county health department of the county where
constnictcd.
i
Form GAY-1 North Carolina DAparlment of En;'iromrxm and Natural Resources-Division of WaterRratec Revised August2013