GW1--00901_Well Construction - GW1_20240205

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I 1-171 5 7
WELL CONSTRUCTION RECORD •
Fo•ittcpull#sc pNt.*: , . ! '
Mils faits can bc uscd fa:filmic tit multitik Wells•• •• "
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I.Well COntractor Information: •
1.1WATER ZONES . •
Brian'Ewing . FROM TO • •DESCRIPTION - • •
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Well Csnitaatot.Natug.
.ft. ft. . 1 . . , . •4240-B ,
AS.:OUTER CASING(fiwinutlkesoleilisIOR.LINER arab-lIcabkr. - • -
NC.Woll CostraOcit,CcrtiftcationNiuit6ei
• • FROM -TO •- DTAMF,TER, lltlaCNESS MATERIAL•
SAEDACCO .. • . _ • IL ,t„,. .
Consul Waft. _IC:INNER CASING OR.TUBING cateiberatal descd-lacp)-• '
FROM - TO DIAMETER TUICKNESS• MATERIAL
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2.Well ConStruction Pertiiit 0; . ... . 0 'ft. 5 ft: 2 h. sCH-90
• PVC
/.ittallaggitilkte well'm43144,04 Calmly.St.rne.:170iatrce.14Extic4o.t.J.
:R. ' I
:'3.'Wall:LEO(ehcelc Well use): , 17.!SCREEN
Water Supply Well: • :• ' FROM. . to - -Matt:TER SLOT SIM 1111ERNKiS- MATERIAL . -
. . . 5- R. ,15- ft. 2 -111. "".010" " SCR-40 PVC
• CIAgYkilltutal CIMunieiral/Publit •
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ft. '
• ElGeotheimal(Heatingtooling Supply)- • 1:3ResidentiatWater Supply(single) . ft. . grt. •
tumour . .
CI Industrial/Coruntercial • I:Residential Water Supply(shared) '• •- ... -..
• •FROM'- • -TO • MATERIAL - ' EMPLACESIETE METHOD&AMOUNT
. - EffniDation• ' • • 0 "ft, - 1 ft. PORTLAND POURED
NOn-Water Supply Well:. ' . . . • .
• It. ' - ft,' i
001Nonitmii.kg-. : oRccoyely . .. .
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Injection Well: • • . . It:, • ft. . ,
ClArptifcr:Rcchirge . ClOrourdnaiicr Renicdiation- •IT:SAND/GRAVEL PACK(if attplkable),:
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'PROM• • -TO ' • AIXTRRLM, ' -. EMPLACEMENT ML-111(1n • ' . '
• PAlptifcrStOtage and RceoveiY 1:1Salinity Partici
3 11.. 15 It. FILTER.SAND : # 2 •
....; -
LI AtittirciTi*I. 1:1StOmovater Dritijitage'• ,.
ft, • it.
EIESperinicntM Technolog • °Subside-nee-Cr:M(01 . .. . • - - • •
'20.,DRILL1INGLOGIiiltach addition:II'slicett-if necesuull
bctrotlig2litaka0s44 Loop) • 15Tracer. . FROM .10 DESCRIPTION(cobr.baronet',wiDnick Div.,0•Abi Am(lea
EiGeothennal(Heating(tooling Return) . DOther(explain under#21 ReniatIN) ,° -'ft.• 5 ft. FILL S yLTY SAND •
' • 5 ft.. 10• D. MOIST SILTY SAND
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4.Date Well(s)COmplited: 12-20-23- .Vike mil TWB07-01
• 10 :1:1 15 rt„ WET SILTY SAND/CLAY '
Sao Well Location: - ..It ft.• .
-7.•
"'t:':Z...=*.A.•.,*'L.:4 '
NCDOT . . . • ' It; . ft. . '
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0
Facflity/OUnerNmac . Facility tpp(ifappikabk)' . . rt... . . . . 5t1t4__...... .
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1-CD
- 1962.Prospect Rd.. Nig,..Stipply, .NC, 28962 . . R. • ft.
- .... ' .7),.,-;• ;i»f".qUtS1 -. -
Pk-skit AO*IbitY-iijil 24.3 il.I.:-REIWARKS" ' ' 1..nfr.rirtS4.-:-I1 ,..:
Brunswick • ' .. - .BENTONITE SEAL FROM 1 TO.3. . Usiv 1/44i ••••—
COOtity ' • Parcel ItittilificallenNe,MN} •
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56.Latitude and Longitude in tlegreeliminuits/seCOnds or decimal 4egteci: 2;,. taiiiikation,. . , , -
Otoe.11 field,one la(dona it guilt:kid) . " '- .. " " - , .
. . -N • • W.. Brian Ei -wng 1/4,2024 .
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-- Signatut Of Ccitified WeliCentractor- "j ,.. '
6.Is OM the well(s): OPermanent .or MTemporary • .
1Pj;signimi,ilif.r.funr!,1 Irergly trig/ Mai thy,It.0.0,t two.64:q19(wry:meted lit awanknre
. widt 15A NC4C.02C.0100 ofr'151 NaICIC.iC.0200 Well doninnetion Standards and gm:a
7:Is this a repair 46 ai;eiistiug well; ElYct or AIN° 'reilir:9f Mir reco.rd?WY NCI ilpyidell 117 All'11ril rn vier,
If dds is a nepalr.1111 out knoiin well consrnirtiorristformarion and explain the nature oldie
repair timkraticynarks:'irciiiikeir cm dig bail pfifili farm., . 23.Site diagram or additional well details; . • . .
You may use Die back of this page.to.provide additional welt site details or.Well
8.Numberof Wells constnicted: 1 . , - Constmetion details, You inay alSo altaeltiddidottal pages if necessary.
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For mairipile lafeedon or rum-igirer siippli wells ONLY lath die same eanitruetion,yoneua ,
' sufmaronelarm. . . SUBMITTAL ENSTIUCTIONS .. -
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9.Total well depth below land surface: 1 . -- . (ft,) 24a. Par All Wells:••Submit this-form Within 30 days of completion of well
For sittildple wells-list di depolts if ctik!leov( ample-3@00-ani'll@i00) Conslfructiolk to the following;
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10.Stade water level below top of-casing: •(ft.) bhiiiiun of Water Resoure0,Information Processing Unit, • .
lf water'level is above eosin::use"+" • 1617 Mail Service Center;Raleigh,NC 276994617
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IL;Doreinde dimneter:°•2 " - • 11n.) ' 24b.For Defection Well‘ONLY: In addition to sending the form to the address-in
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24a aboVe.also submit a copy of this font:Within 30 dais'of.comPletiowof well
12.Well cianstivietion Method!BORED coUstiuction to the following:
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(i.c:•atiger.taiat),Coble direct pink:di:I
'Division of Water Resources;Underground Injection Control Program;
FOR WATER SUPPLY WELLS ONLY: ' -1636 Mail Service Center,Raleigh,NC 27699-1636
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' 24e.-For Water Supply&Inicettonnels:-
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• 13mYield(gpati • MethodofteSt: - ' a P O . .l
. • Also submit one copy of tins frn within 36day ofcompetion.of .
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13b.h Disinfection ty-gel. Amount: - :veil construction Co the comity health,'department of the.countyewherc
• constMcted.
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FormGW4 Noah Carolina Ns:Mural of Envitomacat and Ntintral lie-4314CM-Divides siVsicr RINtat - Revised Aigust29 IA-
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