GW1--05303_Well Construction - GW1_20230814

r WELL CONSTRUCTION RECORD '
Fpa[rlcrml Use ONLY:
Tl;is•folmean.be used fill singlcor multiple wells
1.We1t.Contrnetor lnfoi•rilation: • .
°14:11e1TERZONES:•.
Brian Ewing F'UOs1 10 DrSCRIPTION '
Well Cotwrdclorh:mre. • ft. rt.
4240-B • •
ft, ft,
NC Well Contractor Certification Nwrher "153ODTER•.CASiNG(Gil^ rilti=cassd melts)OR LINER:01 u1i fJcabtc)','...
FROM •TO DIRMETRR TFIICKNESS - 111A1ERTAL .
SAEDACCO ft. . ft. j : hi. •
• ('mopunyNapre• 16ANNER.CASING'ORTUBING:(,eutbeiruteWsed400ji) ...
-FROM 10 DIAMETER _TIME:NESS MATERIAL
2.Well Construction Permit 1; • 0 R. 6 ft. 2.25• -hL NA Steel
Lpsi ell applicobfc web'inf o.n(Lc.Comfy,5tsrte.,Variance,N/87tC.4 Or.) .
ri, ft, in. .
3.Welt Use(041::wwell tine); • 17:SCREEN N .
�faterSiipplv Well: - •
FROM. To oraNtr.TErt sr,orsi1.. Tat1Cxnr_ss 1 MATERIAL
. DJtlgricultuta! ClMuilicipaallPubIhc 6 It- 10 ft. 1.25 in. 004 NA Steel
OGeodi'.lmal •(Iicraing/Coolin3 Supply} OResidentiai•Wnter Supply'(single) ' fie t�. in,
OludustrialiConmmercial OResidential Water,Supply(stetted) to GROUT:..-- -
FROM • TO. MATERIAL EMPLAC•EIIEIT hlE IIOD&A610twrr
DIrrigation . - rl.. ft,•
•
Mon.-Water Supply Well: ft. ft . . . . .
ddhlpni(orine fReeovery • ._ _ w_ ._ _
Injection Well: . . ft. R. -
OAquifcrRcUiargc • . . lICroundwwlarRcniediation . 4.9:SANDJ(RAVLL'PACKtirnijrlicatile _ - .. --- - --
.FIiOM .10 51 VITJ rat, - RM11LACt:Mt.N9•Mt:Tl10n -
A}nifcr Stoaagc and Rccavet5' DSalinity Harrier' •ft.. ' fL
DAquiferTest OStormnitcrDralnugc ft. • tt .
DEpperinicnlalTechnotogt p5uhsidencc.Ca1011:1l 2t DRILIiAG'IOG'fnlluch"ad.. ..,.olstiirlsifnitiissnnl
oGeothermal(Closed Loop) DTr.ieer • FlloM- TO P CItIPT1oa tcctbr.h;mincA+,tr.Onah lytx..r.on max,deer
• DGootltetutal(Heating:Cooling Return) DOtlier(ex loin under#21.Retuarks) .IL. ft.
4.DateWell(s)Completed: 7/19/23 Welt11)1/TMW-1. fL ft.. s 7^�• IE„Z
t.
54.Well LIrcattna: .ft. - rL •
AUG It 'I 2023
.Vanguard Culinary Group ft. •ft,
Facility,'OrmerNouc Facilit>•1DJJ(ifappli;nble). `Rw
716 Whitfield St., Fayetteville, NC, 28306 ft, ft. • cArieti,.
Phyiiead:Mdrrss.Cit5.:und Zip • .:21:R1 MARKS . .
'
Cumberland Grab sample•.with SP-22
•
Comfy • P reel IdetdincotiouNo,(PIN)
•Sh.l.ittitudeand Longitiule in degrees/minutes/seconds nl'decimal degrees: -22:Certification:
(il bred told,ore:InaIouyis-srirni.kad)
r
N W Brian Ewing.
wirr e/1/2023
Sigrotum.ofCertifiedWcllContrrctor Dale
6.Is(are)the'weli(s): 17Penlraitent or 3nTeniporate it".‘signbre thin jinn?:.1 here19•eeriify that 1hy n•rlifs•a hS7tY(fitly)c•.rrsinwIed Lt.g.orrlrtnce-
1V M 15,1 NPIC 02C,0100 or(Set NCrtC 112C.1200 Weil Cuu 0 icrirvr 5randards and rhrrr a
7.LS flits a repair tit an ei:istiny;well( DYes .ar RINo p ofrlrls rrrdrid hers llcerr pmrirlitl rn fl.so ll metien
if lh(s:i):o repo).,fill Aryl keandr aped Co-rtilrudirst:htjprruoilan amyl,xp(nhr the wave of the
repair wrdrr 021'revnreris.-awn or as the hack of this form 23.Site diagr811t or additional well details:
• You may use the back of this page to provide additional well she details.or well
8.Nuniberf oWells cor>strueted- 1 • construction details. You May also attach additional pages if necessary.
.For Jittitriple.ittjeerion.or rant-.rarer supply wefts ONLY Orli rhe.sarue enrrstilfttiwr,year can
sobmitorm form. SIIBNIITTAI,IPISTUC.TIONS •
9.Total Welt depth heloic land surface: 10 (ft,) 24m.For All Wells: Submit this form within 3U days'of completion of well
Fur nrolliple irdkr'l(sr;Mr depN.s ifdi.ft resrfexomptc-•rr'e.00'and.2@s l00l constnictlon to the rationing: '
111.Static water level below top of casing: .. • (f).) Division of Water Resnurces,lnforniatiyn Piucessing Unit.
ifwiiwr kt-rl is abase cras(u(,hie"+" 1617 Mall.Strl'iec Center,Raleigh,NC•27699-1617
11,Borehole diameter:2.25" (in.) 2411.For inintion Wells ONLY: In addition to•sending the form to the address in
24da1>Ove_also submit a.copy-of this lonit within 50 days'of completion of %ell
12.Well eons(ructionmethod: DPT constnicflmitothhefollowine:-'
(Le.3ugcr.rotary.cable.direct push etc:}
• Division of Water Resources,Undergound injection Control Program,
. FOR WATER SUPPLY WELLS ONLY: 1636 Mull Service Center.Raleigh,NC 27699-1636
r3; Vicki(1 arm) 24e.For Water Supplv..*Infection.Wells:
1,. Method of test: Also submit one'copy of this form Within 30'daysof completion of
13b.Disinfection type: Amount: well'construction to the county hearth dcpanrnent of the county where
consttoctcd.
i •
Fame GW-t t'oiL Carolina Department of Encitotwcr0 and Natural Resources-Dlviilon of Water R otrees - -Revised Atrgus3:013