GW1--06578_Well Construction - GW1_20231006

WELL CONSTRUCTION RECORD For Int:nal ifF.ONLY:-.
'Thb form can ba•usel fin.single or utultipk was,
, .1.WelLiCantrattor Information: . . . . . .
'-•.14..AVA.11112.ZONES
Brian Ewing nit0A1 ' .to ' BES6t16rION
Will Conlon:ter Nonie• ' ft: ft.
It. • ft:.
4240-B
ISZOUTER"CASINGiiiiitt P:iiikdllerliV OR LINERlitint MAIO ,..
NC Well CoMractoreertifnmtioni Number
FrioNt ' 70 ••- DIAMETER ' THICKNESS MATERIAL
SAEDACCO •
Compua-Naine- • • ' '.763NNER CASINg'ORqUINIKG:ninothnintal cluni1464C- -_
•Fnost TO DIAMETER THicKNIss • inATERIAL
2.Will tunStructifin Pertnit#: 0 ft. 5 ft. 1 I : 18' SCH-40 PVC - -
Lin Ott applicable tFeif perneit (Le.Camay...Stene.Variance,kettieri , -
3..VYti Use(cheet:well use): . • -17:-SCREEtt..N • ". .
• 7 ••
• . •
FROM' TO -DLANtIaElt• SLOT WI. 7111(1rNMS MA.ImarM,
Water Supply Welh. •
5 ft. 10 - It.• 1 Ili .010 SCH-4 0 PVC
Ottgriolltut.al - Elf4iinidipaiiPlidiC
ft. ' IL. . , -,il-,
Meothennal(Heating/Cooling'Stpply) CIResidential-Watet Supply(single) . •
f3Industrialitomntemini , • . . ..-..-- •, .. . ,-,• ....,•
CIRcsidential illater,Stipply(sinted) ftoGRm '.,1-0-. ' ' •- '• -- - - ' -• - - -- - •• -
NIATERIAL I EMPLACEMT METHOD&AIMOUNT
CI Irrigation • . . . . , 'ft.
. . .
NonAVater Snpply Wen:: ... . - - ••
ft, 0,•
bilMonittnring . . 1:10.ccoyety .
— -... .
Injecalim Well: • - . 0. ft, . .
DAtiniferRceliarge pcinntitl water Rclitediatiou -,IVSAND/GRAVELPACKti(Mnilibter"----- -,--= -
• -FROM •To stAtnium. - ristin.Acrairsir ML-111011 •
El Atinifcr. .1.0rage and Itecoyeky PSnlinity Rattier
. ... ,.... . 3 R.- 10 ft. FILTER SAND # 2
. _ CI Aquifer Test. EIStotninutet brainagc' ' •
.0.. It.
1:MS1mi-internal TeOnolcu 'IDSithSiticacc,totinmi
. . 4DRILLINGIOGIalisili;additieilal sheds
• Ercr*itertnal(Closed Loop) CITracer -.FROM 70 PBSCRIPTION ton r.hardnen.satinet(innei'valn:471.k.(kJ
DGlaultemial aleatingiCoolindRetund DOthet(exploit.under.#21 Remains) 0 ,It!. 5 ft. FILL:-SILT AND SAND .
5 44- 10 IL. MOIST TO WET SILT/-CLAY•
. ,
-I..Pate WeU(s)c.umpleted: 9-12-23 ".war to#Tbal-4
';ft, ft. .•
• .
Sa.'Well Li-mat/OM • •It.• ft, I r:..7...•i:-..::;,(--',ITT 1 ,,A7:-,-•r-t
• 'i .',-f*--.-'t,..r g.:::r s.( '''.7."'_
Matthews Market . . - ft. ft, • 1
. •
tieflityMivoer Name Facility lTht(tearlipjkable). •P. ft. ---7------- -0-CT-0-6-20 23
3196 Vass-Carthage Rd., Whispering Pines, NC,. 28327 ft. •ft. , In fr:nr..- -,71 P r:"L'-z..--.. ,:".•-;I/ 1
- - '
PhyiiciO A4dOss,;Cily...liki'tip =It-REMARKS C ,,,,
• • ' . . -.r., -•,-,
' ''' ' - ' • ';'' '.1:2,',:.•.:::
Moore • bentonite seal 2 to 3'1
. . .
Coutuy . • Parcel Identir=tion No.(kW) 1 • -
• .
. 56...1...atitndianifbingifulle in dcgrcesiminutcsiseCOMIs Or decimal degrees. .22.,eirtificati,im.
(it IAA ftettl;Me.Imam%is-Sullkul)
N W Brian Ewing
9/21/2023
.Signsture Of Certified Well Cotaractor, • • Dale
6.1s(iite)the:well(s)t L1Pernianent or 10Temporaty ite.signing.grit'firth,:.1 irereby eetilly10[4 ihr well( suer(t4te)ennyikeied in,ixeordance
Waif 5,1 jVCtC 02C.0IPO or 15i1 Nate 02e.0200 ir Censtnorrion Sranderas end ihi:n
7.Is this a repair to an Ciastittwelh Oyes Or 10N0 .cti,trof 011r iectinf td4 Peen pan itrivi i•#..16,1 sir,'(Avner,
. (,101/.11Ti repilt,fill out knouvi Well cornlenctiori I ft/pi-maim Win explpin dx..narare of the
jar under 0 21.rerniirki sexirna oi-im the brick"of this forne 23.Site diagnintor additional well details: . • .
iron tnak,use the back of ins page.idprovicteadilitional well Site details:or well -
it Nuitther•Of Wells Contracted: 1 - • construction details. You inay alsOMLich.additional verges if invesSaiy.
For sindriple Irdectlisn'or nunLwater supply'yelp ONLY with rfy same mutt:Mau,}.4,11610 .. ,
sOnkft ii:l PM. SUBMITTAL INSTHCTIONS
9.TOtal.Well depth Moir land surf:lee: . 10 . (ft.) 24a. For AU WeIls: Submit this form within 30 days of-completiOo of Well" •
For marl*ivellsliss idl depths I fdiflrerens fraunple-3@200'funil@l09) ' construction to the fOltoning: • 1
! . .
10.Statiewater lei:el below top.of easing: (ft.) J/hi:shin of Water 11i-iS0n tea,Infiirniation Processing Unit,
' (limier?mai'aim.ensteag,rise"+" • /617 ALIII.Sertieetr'aiter.Raleigh.NC-27099-1617
1 .
if:Borehole diameter:2•25"- 24h.For Infection WellsONLY: 'In•addition to.sending the form to the address in
24aabtWe,also submit a..c:oPy of this fonts within30 days-of completion of irdll
II Well construction method:DRIVEN. - construction[011ie liblioning.!: '
(i.e.anger,ratty,eal?ldirect pasts,.ete:) •
. Whim of Water Resou Tees,truletwouttd Injection Control.PrOgrani,
FOR WATER SUPPLY WELLS ONLY: - 1636 Mail Service!Cdatter,Raleigh.NC 27699-1636
1 •
133,Nield(gum) Method of test:
24e.For Water Sintplv.&Isketion Wells:-
Also submit one copy of tins formWithin 30,days of completion of
134:Disinfection type: Amount: .weil•construction Co the county heUlth department of the,county wheio
consttucted.
Fenu GW-1 &conk=thin Departmentof Emironruent and Natural Resources-Division!oi'Watelr Rmtrcm Revised August 20 LI,
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