GW1--00849_Well Construction - GW1_20240205

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• WELL CONSTRUCTION RECORD rarh�.rialltr�coilv.. - ,
Ths faith eat)bc used far.single ar multipk',cily,
1.*ell Contractor Inforinatlon:
`IJ:.t,VATLRZONEs'
Brian,Ewing . FROM ' TO - ' 'DE,CRIPiION
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Well CoutraaorNatnc: ft. ft.
4240-B .fta ft.
NC Well CotutactorCcnifr]tion Mud*" • ':15 OUTER CASING4thee`inittli=cased eitisi OR:LiNER(tf aji`tteabkil
FROM TO '. -DIAMETER:.( 'THICKNESS MATERIAL--
SAEDACCO f6 R. . 1 Ili.
Company.Name I6.1NNER CASING OR.TUBING_(goibern 1eMscdaoip),•,+:
,FROM 10 DIAMETER. THICKNESS , MATERIAL
2,Well Construction Pen fr:ult . . 0 "R. 5. •. ft,' '2 • I''hi. SCH-40 • PVC
isi all appliti dde,vrll peimits frr.County;Suitt.,Variamre,fiyklictt ate:l' -IL ft. ;.ihi . . . .
• 1
3,Well.lise(Cbe5clt well ose): • 17:SCREEN
Water.Supply Well; - FRO51. .4-TO 'DtAntlints t 4-LOT Sta. THICKNESS d1ATRRtA1.
• Cltln ultinal . .CllafniticipatPltblic 5 fi. 15 ft;: 2 • in O10 SCB40 PVC
g
1 ..,
13Ceetllemial(Heating,toodngSupply}. DResidentia(Water Supply(single) fe in,i
' Dindustriallemi tteicial . DResidcntial Water Supply(shat:rd) 18 GROUT' - ._ - • _ • •. " _ _
. .FROM . •TO. •ALATHWAL . ' ENIPIACLIEVTMEIIIODS`AllOU Tr
CIfriivation•. . 0 ft. 1' ft, PORTLAND• POORER
Non ZVater Supply Well:; R. p ' .
Monitoring • . _: t-JRceov'ray .
Iniection,Well:r .. rt,
DAtlnefcrRecbarge ' IDGroundhatcrRemcdiaiion r9:'SANDIGRAVEL•SACK(if unpticabtel`_s
'FROM -" 'TO' TIATRRW!. . RflPLACFMENTMETHOn
EiAquifcr.Sigiageand Rccavtfk GISalinety Baltic"' 3 R.: 15 ft. FILTER,SAND # 2
- . 17Agtiifc 'Tact . . • ❑Stormhatcrl?rs natae
•:•ft. •ft. • • I •
171 g,enmcn(al Tielinotogy • , JSubsidcncc'Conicol . -
.20?DRILLING'LOG'(altacd addiliori l'shcels i1occessan•1
Mii,othetneal(Closed Leap) DTi ice(; . . FROM .10 . DFseRttm0n a-obi:u,ration,wmnretatype ti mn e.de.
DGeodtelmal(FleatingrCooling Return) .•DOther(explain under RI Rettia,is) u -ft. 5' ft, FILL SILT AND SAND
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• 5 .ft.. 15 , rtr WET SANDY SILT ' •
4.Date Weli(s)Completed:. 1-4-24 . .Wel(1Dd TWB13-01 ft, • ft.
50;Well Location: ft. '- . - - .
1
NCDOT• - ft, ft. • I ,, .C.,,....,,,:A f:,.„i,J gai1.,,.,1• -
.Facilitl•,+Uivoer.NaRre. ' .Factlri)1pp liifappiicable}"
n., ri I h C.d. tl , 7024,
1318.Crooinsb"ridge Rd., Burgew, NC, 28425 . R, , ft,
• Pln3ieatAddIess.Cit3..antiZip' �21:REltiARKS. ' . j iC:ovr:r..ir:yi sot: :. .5=.r.zil,'i' .
Fender . , . 'BENTONITE SEAL FROM 1 TO:31 . U`v v C..;'L'1{y
Cctiall' PanceiItle ilirrcaalionNo.(PIN)
p
Sb Latitude and i tingitude hi deg ei/minutcslscconds or decimal degiscse 22.Ceititieatioue
tltuelt field,oar I tl,lougia surneikM} Brian
R �Y !irr r a n :Ewi n 1,12,2024
SignituteofCeitificdWellCeett;aai • .Daic
6.IS(a e),theivcll(§):"uPennattent .or %ITcmporar ,r irhr this'fang; her( tern' rhur the irel!'s rsys iietn ctrruanrctevl Lr.snarrlmite
by 's bf !n certify (.J 1
frith 15At NCAC O2C,O100 or•15.NCAC 02C 0200;I'd!Conitmcrlon'Statidards and ttaaa a
'7.Ia thist a n.lair to an etistingWell:' OV ti• or I iND • • irivirof rlidr rrroiil has b cri nrorirfid rash.rail mnrrr.
if rlrls'Li a repair:fill an krratin aeticousnuctioa f,rjormnrlwr awl rsplain ilk ware of the '
repaird,itler tn.irwnnLs6rcirmt drill,the bad of ihir jornr. ' .23.Site diagram•oradditional N ell detals:
Yea tua}use the bae6 of this page to.proside additional well site details or siell -
8.Ninuberof veils eontirocted: 1 • •. - i Ottstnietion details: You May also attach iddidatiat pages if necessary:
For irrnlatple 1rr1ectlon ar wrxt,irarcr srrypJv u•cldx ONLY'mirlr illy sane ceiripwMlon,von ow
.subrniroe farm. . CC1BMiTTA►,INSTUCTIONS. I '
9:Total well depth below land silrfuce: 15' - (tp.) 240.1nr All Walk; Submit dais form within.30 drays of completion of:well
Farstratlpla't'lfslisrrtlirrpahsifdt,Qivuil(cxmnri1k,-3@ O0`ani.2@1OO) Conttnietionto the foltptfirig;
10.Statle water level lteltnv top of easing (f,) DiCoiun of Water Resourrcy,Information Piniessing Unit,
ljrr'ah'r le wet'Is itbrne cash;:tile.•'+" I617'MailSerti•icc Center,Raleigh.NC 276!I!lG17-
11,Borcholriliatncter:8_.25" . ,(in.) tab.Farintection Weilit ONLY: In addition to sending the fomi es to the address:in
240abose also submit a copy of this'form within 30 da}'s'of-.cotupletian of well
•1,,Well consti•Tictimr methodi BORED constnictiou tothe following: I
'(La:auger'feta*c}•.'cable.dinii gush.elca - l' 1 .
D6slslon of W-stot Resources,Underground Injection Control Progratii;
• FOR WATER SUPPLY WELLS ONLY: -1636 Muff Service Center,Raleigh;NC 276994434
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1310 "tdd(>zpnil. :Vetted'of test: __ 2 •
4c.•For Water Sattnly&Injection Wctls:
- Also subtitit one copy of this fntuitiritbin 30:days ofcotupietion,of
13li.Disinfection type: . • Amount: . Iveilconstrootian to the county health department of the.couffly lwrc
consinictcd.
Fonu GW-1 RophCanlina Depanckent of Erndmnnriu and Natural Rcsourcrs-Divislon of Water RR oti'e¢ • Re-Lend August20L3
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