GW1--00853_Well Construction - GW1_20240205

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. /11-15b
WELL CONSTRUCTION RECORD - •
Fin Infernal lise pN1..y: i
TO form ern bused for'single or multiple wells;
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1.Well COntraCtor Information: •
',IL WATER ZONES
Brian Ewing . FROM- TO DFACRIPDON I
Well ContrainorNamo. ' rt.-: ft. I 1 ,
4240-B. . • . .rt. . rt. I I
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NeWell Connactat Certification Nuillier • - ild.!OUTERCASING ilikinutii-eakil stilisli•°KUSER/nil-tiCable1i
FROM To , DIAMETER,1 THICKNESS SIATERIAL-
SA .EDACCO •Illt ft. 10. • . •
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Coinpany Now 16.1NNER CASING OR TUBING kimilmranal dosed-loan). .
-FROM. TO IHAMETER , THICKNESS SIATERIAL
2.Wr11 Conitrttition Pasta h: • 0 .ft; 5 ft. 2 . :in- SCH-40 PVC
Lig all imp/folk,wrIl permits(ix.eatrafy,;Snne.Variance,Irjectiag ric.j.
ft:. - . _ft. 4; . .
Weif.Usb.(elteek well tist); - 17,'SCRIEN,
Water Supply Well: . . - FROM 10 'DIAMETER st,or sin: Imotrass 1 MATERIAL ,
5 R. 15 'ft: 2 - •in. 010 SCH-40 PVC
LIAgticuintral, .CiMupaliPublic.
CI
R. . 'Geothennal(IleatingiCooliog Supply) " C3Residential Water Supply(single) . ft:. ht.
El Indusitial/Conunercial .- EIResidential Water Supply(shathti) .:18.GROUT ' , I
FROM -. TO. MATE EMPLACEMENT 31E11100. AMOUNT 1
1:11rtinotion• . . . 0 " •1t. 1 •ft, PORTLAND', ' POURED '
Non-Water Supply Well: . .
. ,all It. ' .islonitori - ecorty " .. . ft
og . ;CIRe I ,
Injection Welk.: - • . . '°Aquifer Recharge' UldioutidWitcr Reincdialion ',Mt,SAND/GRAVEL PACK(if applicable!'"
MOD- T0' • MATERM .1.' • EMPLA CM IENT Sintion
IDAttnireiStorage and 1.kovety ElSalinity Rattier " 3 R. 15 ft. FILTER SAND # 2,.;
ElAqrci Teo. *-13torntwatct Drainage; . • "ft„ It. . . •
ClEkpetimcntal Technolov liSubsidence Control .. - - • • - '• •- • -
• •. .• •"26:DRILLING LOGr(altach additional sheets if roccessarvl
MC#0111,(4MMI. Closeel Loop) bTracer. . MIDST.: To . DEScRtPTIOS Kobr.h anthem,tuCemk Dot.: 1 ritc:de.)
CIGNAlet111.11(Reatinatooling Return) ElOther(explain under.tal Remits) ° ' '14 5 ft,- FILL SILT AND SAND '
5 IL, 15 ft. WET SANDY SILT
.i.:jjaie..wi.efi(s)completed: 1-10-24 ,Welt nig MI1102-02
ft." ft. ' !:•- : 't 1"'-' 7--....
Sa.Wdl Location: .ft. ft ''''''''.- - -1---- ,....., d...,_-i; if i
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NCDOT . - 11,. . ' It. .
. ::-If-A-..t,....1:,.,1 t--„..--,t1,-)cf4:- 1 U'ill
-F' c: a 5 2024
Fac0ityitlivirrilame . Facility WI:(itapplizable) •
tt, rt. •
Chalice.Lane (edge of 5200 Woods Edge Rd.), Wilmington, It. ft,.
NC, 284 09 Ilk-ilea!Aildi.n•Ss,Ork.ilia'Zip' '', R.ErytARNs. .
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• BENTONITE SEAL FROM 1 TO 3
New Hanover
Cutely . . . Parcel Idenlificallut:NO.(MN)
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51i.Latitude and Longitude in degrgesiminutiOseton!ls ti.r decimal thit's..i.w. ..22.
of.Uell ficild;one latilotia is sufileienn• '
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• 'N • W Bna n E_wing. 1,12,2024
• • • , Signature Or Cesitiacti'Well Connector' • , Date
6.Is(art)the well(s):_OPermanent .or .10Temporaty r •
.By:signbig n'O'Ann;'I iierFby certYy irbar..rlig,ilet0.0 WM(ViVy)grimy tied in,awortlancr
Writ/54 NL'AC 02C.0100 or 15et NCAC 02C:0;00 MU Constriakor Paraurds and 11,41.a
7.Is-thus a nepalr to an nsisting nal. ElYo or EiNn -onfkrOf Mk record iias peen p wilder,to ilki'lur11giviter.
If iOislt o repulr:fill pot ARtiliY1 well coogruction information and explain the ourare oldie I. .
repair tiridcr42/.irtnarkiSrciiin or on the hart of Oils fornc. ,2 .Site"diagram or additional well details;
You it4.use the back of this page to.intiide additional well site details or Well
S.Nuntherof Wells Consttacted: 1 - • . . cousttuction details: You May also attach additional pages if tieessaty.
For multi*Injection Or calk-Firer iuppti wel,tONLY with do some constration,you eon ' . • . . • .. -. I .
suipuir one form. . R111411TTALINSTU I
CTIONS. :
9.Tititisvell.depth het*land surface: 15 . , am 24a. For ALL Wills:.-Sulnnit this Tortn within 38 ds nf•compteticin of Well
Foe nuilzipte Ii•elli list at!dephs Ifilifterevo(extroiple-3€1200'anal 2@ 100) constriction to the following;
10.Static water level below top of casing: "(10 DiviSiun of Water RC:soot-CO;Information Processing Unit,
. if fluter let-el tv above casfax-use"+" 1617 Ma)!Senice Center;Raleigh,NC 23699-16 I.7
II.Borehole digrnolen 8.2i 7 'act.) . 211).For infection Wells ONLY: In addition to sending the fonn to the.address.in
.214 abore.also submit a copy of this fonit.within 30 days of completion of well
12.Well etatstivetion method:BORED . COISOUCO011 to the following:
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(.e.augcr.raw.table,direct push.ete..) 1 1
. . Dirblon of Water Resources.Underground fulection Control Program
FOR WATER SUPPLY WELLS ONLY:' " ' ' 1636 Malt Sersice Ccnter,Raleigh,NC 27699-1636
I• ite.-For Water Supply&Inlection Wells:,
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lla,Yield toppl) Airtlioil of test:.
- - .A191 submit one'copy' of this fOittt Withii 30 dayS Of compleflotrof •
131i.Disinfection type: Amount: mil"construction to the county health department of the.conao-where •
constmacd.
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FonnGW-L 1+4'alb Carolina Depart:item of Erwin:anneal and Natural Resources-Division of Water Retooro Revised Mont 2015 . .