GW1--01264_Well Construction - GW1_20240229

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WELL CONSTRUCTION RECORD
For Identol Use ONLY:
This Conn can be used foi single or multiple wells• -
1.WelIContraetorritforntation: ,
I:I.WATER ZONES
Brian Ewing FROM TO DESCRIPTION
WcttCanictnorNam ft. ft.. l ' ,
4240-B fL fL
NC Well Contractor Certification Neither. ,t5.OUTER CASING IfforInutikasedkeels)OR LINER ftf nit.ticabfcl'',
FROM i TO DIAMETER. 'nticttrEss• MATERIAL
SAEDACCO ft. I fL iti-
Cominury-barn I6.INNER CASING OR.TUHING(t ealhennat cfascdaoep}. •
FROM TD _D[A.SIETER. TntCTilESS bIATERL�I.
2.Welt Construction Pcrulit>r: WI0501129 ft, ft. • 'In.
l ist,dl applicable wellpeimits(Le.County,Slate,.Variance,h?jeCIA4 er,;.l' 14
it,
3.Wclt,Use(check well use): I7:SCREEN
Water Supply Well: _ Frost. To tone TBR SWTSI71: THICKNESS I MATERIAL,
IlAgricultutal OMunicipaliPublic ft. ft' •
in
DGeothem►al(HeatingiCooliug Supply) I:Residential Water Supply(single) fL ft. In, 1
DlndustiialIConmiercial ©Residential Water Supply(steered) tfl:GROiFP •
Irri031 TO -MATERIAL . , EMPL(CEMEVT 31E.TROD S ASIOUNT
0kripation - . ft. ft. , , .
Non-Water Supply Will;
R. ft.
DMonito inj .. DRecorcry
•
Injection Well: ft. ft.
CAquiferRccharge 121Cinundnater Renicdiation` Iv.SAND!GRAVEL PACK tic atltrmcahtcl
FROM ' TO MATERIAL ENIP ACi:NFNT METHOD
tJAgnifcr.Storage aid Rccovety lJSalinity Harrier ft.: ft.
❑Agtiifci Test ❑Stomueatcr Drainage
ft, h.
❑Hzporimcnt tl Tcchnolpg• 175ttbsidcnCC Control- 2n.DRILLING LOG(attach additional sheets if oecessaml
❑Geothermal(Closed Loop) []Tracer. .FROM. TO DESCRIPTION tcobr,hnninenr,tanrektym.r!tain n@c de l
OGeotleilual(Heating/Cooling Return) . ®Other(explain wideril2l-Retual1s) ..fL ft.
IL fL .
4.Date Well(Completed: 1-19-24 Well um IP-1 - IP-17 (Even I. Borings ft.. -
5a.Will L nation: f n''
Pantry #176 ft, tt, ��1 L L L.
,, 1�d Sl: .
Faciity,OivterName Facttit}'IDk(ifapptiablc) R. ft. FEB- 2 +
208 Main St., Clayton, NC, 27520 • ft. ft. ' • 202.E
Phytical Address.City.and Zip• :,2L.R£MARKS isIllf ,r•,�
Johnston INSITD INJECTIONS THROUGH DPT RODS'Q/a °I'+L •
-
eowl. parcel Identification No,(PIN)
Sb,A:iltitude aiid Longitude hi dcgrccslminutcslsccvnds tic dccin al ilegt ccs: 22.Ccrtifieation:
Orison field,one;1along.tR:uliicivil} .
N �Y Brian,. ,.Ew'En 1/24/2024
Signature'Of Certified Well°altimeter ; Pak
6.Is(arc)the weli(s): I:Permanent or 10Tewporary 8y.,lighing this fonrr,i ireTby certify what the yells ww•Dim)manurial irr acconhmce
irilh 15:1 NCAC 02C.0107 o.e 15A NGtC 0?C.02ar Well Constrtietioir Standards and ilica ar
7.Is this a repair to an c dstiugwell: 17Ycs or IttNu 'refry of Mir record liasbeen proridcd tote urll owner.
lfdh(sls a repair:filout kloitit w'ellcoasvrncRon brfarauaionand explain the solace of-the
repair wrdera21 renuerks:tircdian ore on the i'r ikuf whir form 23.Site diligent or additional well details:
You may use the back of this page to provide additional well site.details or.Well
S.Number of wells constructed: 8 construction details. You may also attach additional pages if necessary.
For nr ilrl pie 1r{jee}ton or(on-wafer iapp!w wells ONLY with the same cmrstruction,you can
.C,.Nat Otte prin. V SUBMITTAL iNSTUCTIONS
9.Totalwelldepth below land surface: 25.5 • _ al.) 21a. For All Wells: •Submit this form within 30 days of.completion of well
For nrnldlpleN•Clli list all ilepths(fdd,(crent(example-?@200'darf.2 00) ' Construction to tltcfolloming:
10.Static water level below top of casing,: .01) Divivian of Water Rcsuur:et,Information Processing Unit,
if Willer level it vbaie Cd.01e:are"+" 1617 Mali Service Center,RLaleigh,NC 27699;1617
If,Borehole diaincteri?•25" (In,) 24b.rnr Infection Welly ONLY: in audition to sending the fount to the address.in
24a above.also submit a copy of this form within 30 days of.completion of well
12.Well coustivetion method:DRIVEN construction to the following:
(Le.auger.rotas,cnblc direct pink.etc.) 'Division of Water Resources,Underground Injection-Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
13a Veld(gam) Method'of test: 22jc,For Water Supply Zfe Injection Wells:
Also submit one copy of this fern;within 30;days of completion of
13h.Disinfection type: Amount: well Construction to the county health department of the.conufy.whcre
constructed.
FontGW-L Nonhr Carolina U:gsnntenIofEneimivasatl and Natural Resources-.D.ivisionofWaterRtxalriam Rct'tscdAugust26li