GW1--00903_Well Construction - GW1_20240205

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WELL CONSTRUCTION'RECORD Fcr tsternal Use ONLY: I' .
This farm can W usedsinglp or ratipk wcIls• • 1 1
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1.WelidintraCtor Information:
/4AV.ATER ZONFS-Brian.Ewing
" PROM 40 DFSCRIFTION
Welt'corftactor Name, ft. ft.
.ft.
4240-B . ff. -. .
''45.'0131ER CASING(forinuftliedseituills1 OR LINER Una 41eable): '
NC.Well Contractor Ccniftchtion Muller"
vrioN in DIAMETER, ruciasyss. - MATERIAL
SAEDACCO _ O. I iL•
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Comp:UT MEE, ' 16.INNER CASING OR TUBING igeolhermsIdored-lonn).-:
PROST .70 DULADEIER • THICKNESS MATERIAL
.2.Well Constroiiion Fermit ti: - . .. ..
o ft. 5 • It 2 !it!. SCE-40 PVC
. Ust(1.17applinike teelipolitit*ILc.Caunty:-Surm;Varlarree.frfaticet,mc..t.
'ft,. ft, ' in. •
3.WeitUse(chixle Well use); it SCREEN
Water Supply Well:
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- FROM TO . DIAMETER SLOT SIPE THICKNESS I 'MATERIAL
, , - 5 ft. 15 -It. 2 FA '1010 SCR-40 PVC
ClAgtieuitinal 1:1Monidipal/Pnblic• .
'ft. fc •In.
ClGeothetmal(Heating/Cooling Supply) LIResidential Water Supply(single)
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._.I Industtial/Conintercial CIResidcutial Water SuPply aimed) .:m18:0GR„43.171 ,in
t.SLI:TER. GIL ENIPLACE.- MENEMEIII. OD&AMOUNT'
CI Irrigation-. , .0 ' . ft. .1 .•ft. PORTLAND POURED
'Non-Water Supply Well: •
ti., -
Illiit4onitoring . EIRecoyety . . • .
Injection Well:. •' - - • , , It. - . . . • , ,
L3AquifcrIiccharge C26n?uftdwiticr Rentediation .49.SANIUGRAVELl'ACK(if amilkatite)•
• ---- • - -. . . 'FROM- "TO • MATERIAL • PAIPLACLAIENT Mi:tHOli
ipillerStoragc and Re&wrctf EiStilinity.Battier' 3 .ft.. 15 It, FILTER i SAND # 2
EIABlififc!"Tsst - " -
13Stormwatct thairi. . .
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ZI.Eicpetimental Teehooloa IDSubsidcn .cetontrol . . . .
••_ - - --NV ORILLI?iG LOG"faltach a dditionfal i . .iheetilf-neccsuint
Opeotherinal(closed Loop) . tltincer. .F1105!• TO • DESCRIPTION Imbr.IiiutIncri.svIenickintt:gold ride.HO
ElGeotheitnal(Regina/Cooling Return) . Obther(explain uatier.#21 RetnadmI ° 'ft-' 5. it, FILL SILTY SAND
5 'ft. 10 ft. MOIST SILTY SAND
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4.13, Me Well(s)Complited: 12-20-23 ,Ax,rki um n1305-01 ., 1 , •
10 . IL 15 fi. WET SILTY SAND/CLAY •'.
5a,Well Location: .IL itt.• I -,„ip LL.,,,.,f'.'',-if— -.,—,7- -
2 '.1.1:::LH' )
^..,a_ . -
NCDOT 5 . ft ft. It.L • 1 ,
Facaitynur Name '' . facility II:0(i-appiiukic) ' ------17---- ---F. --EE----0-5-2-6(14
. ft.
Camp.Branch Rd NW,.Ash, NC, 28920'
- - • . ft... ' ft. . InfrIrr. ";:7°:-Z114. USX
Pk-tidal Aitifteis„Citk..inft2ip• „In:REIHIARILs *,,J‹.n i"-h 1
BENTONITE SEAL FROM 1 TO 3' " .
Brunswick '
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Cously "
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. pat'co ItletilittCatIon No,(PIN)
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561.11.ittititdcMid bingltirde lit riegtleciftplituteitsecrinds Ur dcC MM!itetecter: 21 certification:. i
fttnell field;o .lationi is•sufriekul) . .' ". I
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W Etrian EWIng 1/4/2024
' Signs=Cf Certiried4Viell Contractor
6.Is(.ire)the well(0): tiPermmtent or' roTemporary 1
•Ify..1i:gtiin'kir fang;'I Irer;1?),cergry 0€4,the wilits)tius On.)cerwnifelett an(tett71141Ce
tad!FM NCAC 02C.0100 or ISA NCA0,02C.020P Well eonstrnetion Standards and slim a
7.fs'this a repair to an existing Well; ElYes .or KIND .•rcsir of liar record.lies Ihjcil provideitto#Of menet;
//Sysir a repair Jill out kuhen well consIntaket Intommrion and explain the nature of the .
reparander mki:iraiaii P21 iiter ai-am Ihe bark fith m.tis for . 23.Site w diagram or additional ell Itleht8S; . . .
You.mq.mse the back of this page M.provide additional well site details or Well •
8.Number-of wells Constructed: 1 . _ consiniction details, You may alto attach additional pages if necessary.
For Mild:*(althea,'or amtleater supply wellsg.Nly with die same etursieuetIon,yon can . .._. - 1 .
.sufmit 00E10nm: . SUBMITTAL INSTUCTIoNS'. 1 •
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9.Total well.dcpth below land surface: 1. (tio 24a. For AU Wells: 'Suhtitit this form. -Within:30-daya of•completioti of welt • .
For nnilfiple'ill's-list all depths if dike rem(exampte-3E1200'Cilld 20 laR) . tonstractioO to the following: 1!
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10.Static water level below lop of easing: • (ft) Division of Water ReSourcOS,Information Pracesaing Unit,
If lit lei level!calmer easing;use"+" 1627 Mail Service Cciiier,Raleigh,NC 27.6901617
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1L Borehole dianicherr8!25" . 1'04 246.Far bilectiou WelNONLY: II6 addition to sending the form to the address-in
24a above.-also submit a copy of lig form within 30 days of completion of well
12.Well construction Method:BORED C61111E8011 to the foiloWing: I ! -
(ic:auger:molly.cable.direct Fink etc) I- : '
'Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ' 1636 Mall Service Center,Raleigh,NC 27699-1636
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Ste.For Water Supply&InjectionlWells: .
13a.Yield(gym) 'Method of test: •
Also sublitit one coPy of thi faitri'Within 30,days Of ComPletion of.
13h.Disinfetition,type: Amount: well eonstruCtitin ii)the county health'depaument of ilte„county.where
• constnicted;
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FatinGW-1 North Caton=FIcpiutricnt of Enviromuest aid Natural Resources-Divirion of Water Ratrcis. Rivised August 2013 •
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