GW1--05304_Well Construction - GW1_20230814

I
WELL CONSTRUCTION RECORD
For[menial a �x1 Y:. •
'fhis•fonncan bused Cm singlear multiple wells'.
1.%Yell.Cbatrattor InforrttaUntt:-
•
,:IJ:3tiATER'ZONFS • .•
Brian Ewing - FROM TO lF_SeR1PtION ' •
SW11 Coi tturtor N4nt4 ft: ft, '
9240-B ft. ft:. ! 1
NC Well Contractor Ccrtiric�tior Muellert5:OUTER CASiNG`(fnr mafl-ea`iietI ndJsi'OR L1NER'dii alf itlesble). :_ •
FROM 1 TO • DIAMETER-. TrnCKNIIss MATERIAL,
SAEDACCO fl,; ft. la.- •
('9mpautytraii. Ui INNER CASING OR TUBING'igiotbenn:J'cfascd.loap.
FROM TO . DLAMETER • TIRCKNESS • %IATERIAL
• 2.WeU Constr3,ictlon Permitif: 0 ft. 8 , ft, 1 :ui: SCH-40 PVC ' '
.. Childsmiiirobktveh'pCm �wL (isr,.Gouty.Stale,Variance,ineett)b etc.,)- .ft. .h. • i><. . . .
3.4Yell time-(checl:rvdl usel,, XL-SCREEN -
R W.itcr'Sopttiv We1L htt FROM- TO tamatc surf'sox 7nIC eNt;ti rin s 1 MArtmr,
8 ft, 13 fr. 1• in, ,010 ' SCH-40 PVC •
CI Agricultural E1lvtiinicipalfflublic .
• . OGeotliemial(1<icatingiCooliug'Supply)• - DResidenlial•Waler Supply'(single) G, .fr; in,
DAudustrial/Couiotercial ©ResidentialWater<5upp13(shared) �t9iGRO(1T " ;. __. . _.... _- -- .: -
FR051 TO. MATERIAL1•CNIPLACE1iLNTh1EfitaDSA.MOUNT
❑ltrigatian' • rt.. ft,-
NuMAYater SupplyWell:. . .. . .
6i11v1pnitoeini . fRonlrl}• it.. ft
injection Well: R. ft. •
MAgteircrRecharge - C]I3rotiiidr►:tter Re:mediation :-19:SANDIGwt4'RL•tawcrcylr a liplii3l:ttr'` ---_;_.,.... _:_.._... _- _ _
EROSI TO M.LTr:Rram. .EMPLACEMENT ME-rilntl '
t1Agnrfcr-Sloragc and Reco%ety OSalinit} Barti-cr
6 R. 13 ,ft. Filter .sand ' #2 .
❑AgiiieCr'cst . ❑5lvrtiinatcrbt,tinngc
, rt._ tt.
Et:tpatiniaidat Tcchnolo ' D5ttbsictcncc'Control •
�2n;DRlLLUNG'LOG7attach:ed4ifionalslicttilliteccssnrv1' -
'❑Gtotltemial(Cldseil Loup) []Tracer FROM • 70 DESCRIPTION Imbr.I,nntnce,.011 m th Om wain An..,..cer.I
❑G othemral(fieatinei'Cuoltna Return) • ❑Outer(explain under:#21 Retnaukss) ' . .it. • 'ft.
ft:. II'
. • h �'.,go�s
. . -:Date V kU(s):Coutplctcd: 7/19/23 • Well ID#TMW'2 �" �°"° a
ft. ft, •
11 •
• 54:Well Locating: .ft.• r• AUG' ❑ Ji 4 2023
• • Vanguard Culinary Group • . .IL ft. � eFa.'ur�a> +a,�Ili
Fecility,!On•ncrNanae ' Facilitj 1D,4 t9Capptiable) .
R. ft: `�
716 Whitfield St., Fayetteville, 'NC, 28306 ' ft. - - ft, .
Physical•Addrss_.City-iiuI Zip 21:REMARKS' - ' ' ' .
Cumberland Bentonite seal from 4-6' • '
County Pared ideMinemion No,TIN) . .
li Latitude.and Longttterle in devembninutesdseennds ai decimal detract'. .22.,Ccrtifirrfion:•
(itoen*id,one I0104 iar strifiIkaal)
N %Y - Br pn E in 8/1/2023
Sigrntur afCertified'W'ell Contractdr' . ' • • Date •
6.Is(are)the•rvoil(a): L7Pu-iii.lent or >aTentporar}' 6 rgnbrg thii.k.tm,.1 hcrchr e•err!fi nor ilia•irel!(s_!4sm1.1'fri tel eqn,ilrigleil km,v'®rYknce •
•adith r5,1 NCAC 02C,of9,9 or lSrt.NC,1C 0;C..0200 A a lJ Cuatsti;irrenn Sfooticrrds irnd Ana
7.I.tllis,a repair to an Crrititlgweli7 ❑V..s or ®NU topr.ofrhir r,roieJlaOi.two ptnrided rit4be,n:fl owner,
(f;. sLt o rep rir,fill agar krtoia i W it tVitirtifcttoti 1irforemrtlon ono!attiataht rht tutrare of the
ro iarr raider dj_1'relnarkr.+rrtian or an the brut of tlur fornr. 23:SLte dilt,,l'81n or additional,well.details:
Yon may use the back of this page tol.prosidh:idditional well site detains:or well'
8.Rytnberelf wells caustrttcted: 1 • commence'details. You May alea albeit additionalµalges if nL'cessan-
- For aitultlpk ht(eetlrn'or oroa-raiarer supply trefls ONLY WO te.snirte cotrstriwt£ntt,you coo
=Omit cerr Yuan. . SLiBMITTAL INSTUCTJONS -
9.Total Well depot belotw land aerfnccc i3 [ft) •211..Frar All Walk' S.ilhmii this form withiti 30 clays of completion of welt
For itru rlpkc krlf lfsr all depa'e if different(example-3@200'ono,.201t37) consiniction to the folk:ging:
10.Static water level below top of casing: (11,) Uivisitin of Water Resou ruck,Infnrmattign 1Prneessing Unit,
1f writer level is above eostiap.'OM"+" 16171FLtil.Scrvicc Center,Raleigh,NC:-27G99-IG 17
11.Borehole diamtcr.2.25". ' (in.) 24b:For rifcy:ltore Weds ONLY: In-addition to-sending the form to the address in
24a above_also submit :Leapy of this forth n•itlliit-30 da1's'of conviction of fell
• 12.Well consttuction method:DPT ' • • . construction[gibe follodiine::
(i.e.auger,tatty.cable:direct push,etc.)
,Division of Water Resources,Underground Injection Control,Program,
FOR WATER SUPPLY WELLS ONLYi • 1636 Mall Service Center,Raleigh,NC 27699-1636
13;>k'lficld•(Wm) 'Method of test: 2.4e..For Water Supply.act fn_jcctfoa Wells:
Also submit One cony of this:form within 30'days of completion of
flab.Uisinfednn type Amount: well congtnictioii to the county health department-of the coimty�where •
• • • constructed.
Fenn OW-t Noah Carolina D panmctu.of Entdraiuticut and Natural Resources-Divisloa olvaier Rrkau Revised.Au tact 2013 .