GW1--00855_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD For[Mental uscONLY: .
This form can bc•uscd for single or multiple wells• i
1.Well Contractor Information:
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',14MATER ZONES-. .- •
Brian Ewing FROM TO DFSC'RIPiION
%Yell CotwraclorNanne ft. R. I 1
4240-B tt. ft; I ;
NC Well Cant orcanhIliLlonNnnile: • AS OUTER`Ce1Sil+1G'Rnraiulllliyed'littlsYORI.iiYEiC(LPi,pineabW�
FROM 9 TO • OLAND:TEit I •THICKNESS• MATERIAL•
. .SAEDACCO .rt. 1 rt. ' iu..
CorrgtNtyNiiue f:t6 INAlER,11CASING'OR=TT.1®1LVG'{giuiberin:lclukd-luoi a•_. .
FROM TO DIAMETER• 1 THICKNESS - MATERIAL
2.Wclt Consn'uctien Pen tit#: 0 R. 5 ft. '2 i' trt SCH-40 PVC
. Liss trfl appliaibk wellpemmfrs(ix.County'.Slut',Variance.fryrec041 Kr.) ft. I ht.
3.Well Laic(cheek Well ase): =I755CREEN' - ' • - . .. - -- -
Water Supply Well: • . ' - - FROM •TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
1]Agticttllttml rlMuriicipal/Plllliic'i 5 ft. 15 R. 2 iq. 010 SCH-40 PVC
13Gcothetnatl(l3eatingleooling Supply) °Residential Water Supply(single) fh ft. in,
D htdustrialiConmteicial ©Rcsidcntial.Water Supply(slated) =ta:GROUT'
FROM TO AiATERLV EMPLACEMENT METHOD Q',55IOIINT '
❑ltriptltian 0 ft. 1 fti PORTLAND POURED '
Non-Water Supply Well: . R, ft. '
lighlonitoring ❑Recovery ,.
Injection Well: .tt, ft
DAgttiferRectiarge °Groundtt tier Rentediation I4 sANDJGRAVEL•PACK(iI.uirpllcabtoY' --- . -_ _ __--.
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VnOM TO N1A'rE;RrAt. NMIPLACtMVNTMI:t•HOn
°Aquifer Storage and Recovery °Salinity Harrier. 3 R. 15 ft. FILTER i SAND ti 2
CI Aquifer Test DStomt%atcr Drainage.
ft. rt.
❑i xpaiimental rcoimol,Qgr DSttbsidcncc C'o1li.tol ' .20 DRILLING LOG'fidtacti'nddlitiomd ehrdslliweesnrri _-
❑Getltltennul.(Closed Loop! ❑Tracer .FROM TO' DESCRIPTION(wbr.1 axdiic i.xdur+Mkwtx:r-rutn nire.det _
❑Geotllelntal(Heating lCooling:Return) ❑Other(explaitL under 0 I.Retnatks). u .(t• 5 .f1, FILL SILT AND SAND
5 ft,. •15 ft, WET SANDY SILT
4.Date Welly)Coutpleted: 1-8-24 Well 11omTWH101-03 1l. ft
Sa.WO L:lin ttuu: ft. rt.
NCDOT ft: . ft. I• •
• Imo.. , ,L.ii fare .1 1
Facility,;Otrricr-Ntmie Facility 1Dk(ifappli:ablc).. - ' "'
n. R. I-rr; .g 5 2024 .
202 Asheton. Rd., Wilmington, NC, 28405 ft, ft I
Physical Address.City.and Zip. >21:-REMAltKS'•o' Ili 3r7: a Fl Pn :^.-:. !i....
New Hanover BENTONITE SEAL FROM 1 TOI3' D}.sa4Q-3 --' """
Cwmly Paten]ldealifcatiou No,(PIN)
•
Sb.•Latitude and L9ngttnde in degrer,sfminutes/Seconds or decimal degOccs: :21 �`
(U'i ll tkk'Id,oio.la67utig.is Strilicicat) 'Ccttit[eutlnn: I1
• • ii N
• W Brian',n,E i_r .g_ 1/12/2024
Sigruiureof Certified Well Contractor' ' i Date
6.Is(are)the.wcll(s)r IPer:anent or xTemporar}' Eh• i'
• signingrhfr}urrrr,I hercbr Terrify shut ncu vYll(.+)t+us(wrrel•eursrrnretarl ire ay.•aorrlaticr
!vith HA NCAC 02C.01(k0 or 154 NCrtC ir_C,020011W!COustrorNar Standards and that a
7.Is this a repair to an et sting.p'c11: bite_ or KI No rape ofrlur rernnllass been provided to the,well(miler.
if Ads.is a repair,fill art koniwt aril csrn trio:don Iuforrnerlon warl erptaln the aware of the .
nliair fender 021 reninrkxs.criim or Cot the had ref this form. 23.Site diagram or additional.Well details:
You may use the Gael:Of this page to Provide additional well-site details or welt .
II.Nmltber of Wells constructed: 1 cotlsuuctimt details. You May also"atiacti additional pacts if necessary.
For rnaltlple inJeection or arm-rreirer supply wetly ONLY WO)the.saina cnrrstriwtwn,part,ran I
sabruit are pnmi. SIIIIMiTTAI:INSTITCTIONS 1
9.Total well depth below land surface: 15 (f,) 24:r. For All Wells:: Submit this femur wItliin 30 daps pf contptetioti of well
For sadllp1ee rvells'list allifuviks Ifdifferen:(t,rtmiple-J@2(30'oafl2@F00'y' Constitiction to lite flrlIoning: I 1
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10.Static water level below top of ca.§iugi 01.) Division of Water Resources,Information Pnicessing Unit,
1f WOW'keens above vas*axe"+" 1617 Mail Service Cenjtcr,Raleigh,NC 27699-1617
IL Borehole diameters 8.25" (in.) 24b.For Iniecton-Wells ONLY: Lit addition to sending the form to the address-its
24a-above.also submit Is copy of this form within 30 days of completion of well
12.Well construction method: BORED _ construction to the following: 1 '
(i.c.auger.rotary.cable,direct push.etc)
Division of Water Resources,ifaderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I636 Mall Service Centel;Raleigh,NC 27699-1636
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24e.For.Water:Supply&1nkcfton Wells:
r3a,Yield(gpnl) MathodoftGs't: Also submit one copy of this form iwithin 30 days of completion of
13b.Uitiufeedun,tipe Amount: wed construction to the-county health department or the cotitity where
constnteted.
Fenn GW-1 Montt Carolina Department of Fni'ironnl`w and Natural Resources-Division of-Water Resmtlas Revised August 11113
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