GW1--06599_Well Construction - GW1_20231006

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WELL CONSTRUCTION RECORD rcr humid U ONLY:.
This foria cot bowed foi single or multiple wells. ' ,
1.Well.C6ntraetor Information: •
`1J: YAfER:ZONIS.
Brian Ewing FROM.- 10, DESCRIPTION
Will Codracfor Nark. ft, ft. 1 r
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4240-B •
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NC{Yea Contractor CcttiftcatiouNutrlict 'IS;ODTER=CASINGthiinnHizei eilnetlsl`URLiNERtitiin ticsDtc)•.
GRO,t - TO DE.{METPR• THICKNESS-• MMATERtAL
SAEDACCO , , .rt. fL I j ln: /,
Comp;uryMamC• • `-t6;INNER CASING'OR TUI ING:Aflt l 4b ana ctarcd400p) '' .
FROM TO DIAMETER TtHCK,W.SS- M1ATERIAL
2:WelitonstrtletionPertnit#; 0 :R. 20 ft. 1 I -'hL SCH-40 WC
Lisinil oppilirobleiFeil perydis(ix.C uriuy.1.s c:.lrorinrrcr.InjettliM_etr,.)' - ' ' -
• ft. ft, 1 `ur.
3:Weit:Use(checl.w'dl use): 17:SCREEN y
�VaterSulilif�Well: - - FnO)1 TO D?..tSIETF',R' ir.OTSIFF, • T1ttCKNI S MATIiRr,%t.-
ClAgticultural CJI4IanicipaUl?ttblic 20 ft 30 ft• 1 ill. 010 SCH-40 PVC
OGeotltemat(HeatinglCoolingSupply) °ResiidentialWaterStlpply'(single) R: •ft.-. �. in.
llludustrial(Cou erciai. ®Residential Water-5uppis'(shoed•) '1a GROUT
rn ... . __
FRO\I. TO._ MATERI&L EMPLAC'EMLNT METHOD S AhlntNi
El irtigatiOn :ft. ft.. bon-Water Supply`Fell: ' - .. -
• RihIonitoring 11Recovely ft.. • fl ? • T -
Injection Welt: ft, ft: '
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DAtfltifef'Recharge. - OGiouMinzitcr Reikdi;ltiou -4L4LSAND/GR,i4'B1rPACK'tif a'ry l?'= -_--
ille4M - - • :: . . - . - -
•` :•t'uOhl TO - MATE:Rm. - •I iPI.ACE.II5TMETROa
[7 t inifcr.Sloragc and Rccd%�ct , DSalinin,Raiticr 18 R. 30 tL FILTER SAND # 2 •
C!rtgnitcrTest C75toiRtnrterih;tinti e .
ft.. ti.
ElExperirnenlal Tcclindto I7Stibsidepecennitol
'2tt:'DRILLiN_G E G'(ntt;teh'additional sficeti if iteecssnrp-
t7Geoihennrt(ClnsedlLoop) .DTrdcer MilM- TO= DFSCRIPTION Cole.hnrtlneat.RillinrtitRIX.:xidn .till
0Gaotlteimal(Heath gucoolludRetum) ClOther(etplaitt under.:#21-Retuatks)' 0 ,It.. 5 0, FILL SILT AND SAND
. 5 R.- 10 ft. SILTY SAND
4.Datc Well(s)Couipletcdt 9-14-23 Wit[iD#TMw-2 . . .
10 It:, 15 . tL WET SILTY SAND
5d;WcU Locatitru: . • 15 ,ft.• 20 fl, SILTY SAND MOIST TO WET CLAY •
Kim ball Auto Glass. 20 '-ft,� 30 ft; CLAY.PWR c^, T_- -.�
Facfity,01A•oci-Nume - • Facilitj'kik(tfappl)cnble). Z,'4� , I Ti-
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748 N. Main St., High Point, NC, 27262 .ft.,. ft. �•
O r.r p 1' 2023
Physical`Ai11 ss City:;(1.2.1l '2tiREIWARKS.
Guilf Ord •BENTONITE SEAL 16 TO 18'' tf'.iidiT(.'-`,ram it %).-,,:.`,F,7.4'a, I r
r.
County parcel tch:utitt»tier 10.11}IN) I>:°`3s:1`'�3
• Sii.IartihideandLongitude in dcgrceitminutestsceands 0 decim:il degrees: . _22,Ccrtificatforr.
Htuoll friolitome lath9 lis'sulflckill) •
• !Irian
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N • W ! is 11Ewi_ 1 9/26/2023
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g®air gf Certified Well Cantcretai Oak
6.Is(tire)the:well(v}i"fPennanent ,ar 50Temporary ,I a'Ig-2 - i1rir fnim;.a hereby eerlifv IlJnr tlic 7r a//(51 kuY 04019 am:whirred bM1,GeY'4rY4m[Y
i idy 154 NC,tC 02C A100 or I54 NOW. 02013 Weil ConstJrictiar Srarsdardsand rb,u,i
7.4 theta repair to an eustin,Zwell: DYes nr KNo 'ecp'oftir r.1ron1 big-been pn 1'ided(nitre time crime(.
Ifrl.'(s:lt 0 r'p Tlr.frll tcJrltoo11P11i'ell i 6m-mnrci(oo'lrrformmion and eApinln rbe,iiorare of the -
iinOir rarilca'N21.rewirks._.*liar oronn Mc bm o f this form. , , ..23,Stte.tliagraui or additional well details:details:
You ma}.use th'ebact of this page to:pio ideaddilional well site details,'or well
S.hitntberof Wells eaustructed: 1 -consuuctfori details. You item'Also attach additional pages if necessary.
For maiiip c.hrfmion,' ,u iLauer supply irells.ONLY filth Oe.amngrorrstryeliorr,.yoPeon •
Omit mpg'farm. . '. ' . - SURMITTALINSTUCTIONS -
9.Total well depth hetow'land surface, 30 - (ft.) .21a..For AR Wills: Submit ens-form within 30 days-of eontptetioti'ofwell
For maliiplelcelklisrall depths ifcliff.rear(eronjrfe-Y@200'rind.:€d0J0) • constmetiontothefoltoninn; '
10.Static water lei'el below tap of easing (ft.)' Uii'Esian of Water Rezpureei,Infiirniutiun Prcieessiiig Unit,
. l/aril a/er'e/is above eas(rag,We +" - - .16171Huii.Seil ice.Ccafer,Raleigh,NC-17699-1417-
11,ill:wantc diameter:2.25• ". •'((o,) • 246.For'Palmetto Welly ONLY: t i.addition to-seudil►g.ihe fame to the address in
24a'abos'e also submit a•copy of t•his fowl within 30•days'of cornpletioui of net[
12.Well constructiou method:DRIVEN constnict[tm hi)the follonine!. '
(i.e.auger-ictary,cnble'dilect post!,cte..) •
Di%'isioit of Water Resources,Underground Injection Control Program
FOR WATER SUPPLY WELLS ONLY:' 1636 Mail Strike:Center,Raleigh,NC 27699-1636
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131I,'lo icld al) MciUorl of Sett: - 24e.-For Water'Supple.&Injection Wells:.
�T Also submit one:copy of this';farm within 30:days of conit)letion.of•
Lib.Disinfection.type Amount: - well-conslmction to the county health dcpannlent or the county where
eonstwctcd.
Form GW-t • ' Noah Carolna Depan nen ofFm'irrinttncn1 and Natural Resources-Dh•isloo of Wale R otrcm Rst•iscd August 2013
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