GW1--01411_Well Construction - GW1_20240301

WELL CONSTRUCTION RECORD For[menial use ONLY:
This form can bnosed fdr think°or moltipk wells• . 1 •
1.Well Contractor Inforatation:-. 1
•
'"141.:WATER ZONES'-. . ., L, • • '•.
Brian.Ewing . . . - FROM • 110 • MSCIOOTION
Well Corn-mot Name. -ft, R. 1 1
ft. ft.. . 1 1 .
4240-B
NC Well Contractor Certification Nitijiler 1 S:ouTftft CASING tfOr'indllkMiettnells)OR-LINER(Kan`fteoblek.
FROM TO •• ' DIAMETER ii THICKNESS MATERIAL
SAEDACCO
. . • • - - -
Computy bionic 16.INNER CASING OR TUBING(tcothernaal doscd-lone,L.1
• FROM TO DIAMETER. _ THICKNESS MATERIAL
2.Well ConStructiOn Perinit#: . . . 0 -ft, 15 ft; 1" . ut. scii-40 PVC •
List 1 apOlicade wr11 permits(Le.County;State,Variance,!leak%ele:.1
-ft, ' ft.. . 1 1114• . .
3.Well.Use(cher':well use): £7.SCREEN '
Water Supply Well; - -- '- - - - FROM. ., TO .0tAarET1111 SLOT SIM THICKNESS. SIATERTAt. • -
15 Ft. ,25 'ft.• 1" ill ''.010 SC.H-4 0 PVC
.0AgricAltural 0Munidipal/Public•
O
ft. . . . . .Creotheitnal(Heatingtooling Supply} OResidential Water Supply(single) ' ft. Ia.
. • 0 ludustrial/Conmtercial . OResidental Water SuPply(shared) L C/P ill" To' .MATERIAL -. . . -. _ _• •.• -- ..- ..• .
• EMPLACEMENT SIETBOD&AMOUNT
. ' 0 irrigation . . . . • . -ft,.. ft.
- 1
Nou-WateeSupplj;Welt:- - • " • it... 'it.
. et M011iblrilAg . . pirecovery • ,,
•-•
Ittje.ction Well: . . • - •ft,- ft. : . •
0 Aquifer Rcelirga • Odioundirater Reinediation •I9 SANII1GRAVEL1 ACK•tif apidicabfriV • .- . ._ - -.
•FROM-- - TO' ' • NIATHRIAI:. • , PAIPLACLAIENT mullion
0AimiterStoragc and IteCovetY: - ASalinily Hairier 13 ft.• 25 ft. FILTER SAND # 2
0Aquifcr Test. . OStonnwater antinagc . 1 .
. •fr.. ft.: . .
OE*erinicullal Technatom - oSchsideme Conirol . . .
lo.'DRILLING LOGIallack•additional sheds if ibecessarvl . '
EIG,eothermal(Closed Loop) OTracer, .
.FROM TO . DESCRIPTION Kobr.Willow.suITotek Opc,.'oraip wife.Ht.}' •
• OGeodtettnal(Heating/Cooling Return) 00ther(esplain under 621 Rettia&s) 0 '11. 5 rt. FILL SILT•AND SAND • -
5 ft.. 10 ft. SILT CLAY MOIST
4.Date Well(s)Contpleted:-2-6-24 .well FD#TMW-2
'
10 it:. 25 it. MOIST SILTY SAND/WET
Sa.Will Loc.atiou: . .ft. ft.-
Holly Springs Exxon - Quality Food Mart it, - ft, .
,.
.•!.--• ,-.--.... ^,....•e, ^ • ' .
FagilityirtiVneqinEg . '. . Facility lilt(itapplicable)
1, •fL: 1 1 —; V 11."-•( •
' 300 N. Main St., Holly Springs, NC, 27540 . . . .rt. it, I FlkalAddress,CitY.ancliin. „:2L,iii.,/OARKs. , . ,MAR -0 1 2074 .
• Wake , . • . . .BENTONITE SEAL 11 TO 13'I. •
. . inforr,r,r-li^n ! ..,-.- --•
Carroty parel IcKillifiCallOa NO.(PiN). DWOjnOG•
. .
Sh„Littitiide Mid Longitude in degreeiftninutessecOnds nr decimal degrock 2, cadifi tatiow•
Omen nektonic IatlionaisSurfiekol) 1 .
• ii 1 1
. . . N • - •• NY Brian.. Ewi:ng - 2/14/2024
. Sign:tweet CertificAciConnacta;- !' • Dale
6.Ls(are)the well(S):.OPermanent ,or ETemporary
11):aignhv this fano,1 heTby err*thatl.the 1144 xis(were;arnrtnicred 1rt amortlanee
' ' • irith/SA NC4C OW.0100 or 111.NCACO2C.0299 We Conieffletiot Staiklanis and that a
7,Is this a repair to an ciisting well; OYes or Irmo. .ceiiy of dill r..corri ha bel4pmyiefett AY th i';mrll(+leper,
II thls'Is a repair...fill Oar firwitii well calwritcrioa Information and eiplahr the'mare of Me
repair under 021 remarks ieefido or On the both of still faux • 23.Site diagram or additional well details: •
: • -You may use the back of this page to provide additional well site details or well
8.1Number of.wells(yammered: 1 - • . . - Constmetiondetaits. You-may also-attach aidditibnal pagei if necessary.
For Junkip1e letieedon araRII-Vorer hp*wells ONLY with the untie cortsiruelletr,yoit can ' ._
=Omit One forrn. . SUBNIITTAL INSTUCTIONS1. 1, ' .
9.Total well.depth below land surface: 25 (frt.) '24 km At!Wells: Submit this farin within 30 days of compfetiou of win!!
For mild&'wells list all&Ty&ljdiffero0(exampre-30200'tau1.2*100) . canstructionto the folionini,.: • • 1„
l•
10.Static water level below top of easing: (ft.) Di-!ion of Water ResourceS,-Information Processing Unit,
If welter level Is'above Cadag,"afe."+" [617 Man Service Cenier,Raleigh,NC 27699-1617 .
1 11
11:Boreholcrlianieter: ,25" (i11.) 2-1b.For Infection Wells ONLY: In addition to sending the form to the address-in
24a above.also submit a copy of this,tram within 30 days of completion of well ,
12.Wcil Mustiyetion method:DRIVEN . . coffilmitt on to the following:-
(Lc.-nun:rotary,table.direct posh.etc.) :.
. 'Division of Water Resources,Underground Injection Control Progratit;
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
• 1 1
24c.For Water Sun MY&[Mention Welts:
11,1a,Yield(gpm) Method attest:
- - Also subridt one copy Of this'form'within 30.days of completion of
13b.Dftinfenthin.typm Amount: • . 5N.ell COnstmetian to the county health department ot the county.where
.
. constnicted.
1 .
Form GW-1 Noah carotins Deparintein of Emig:mein and Natural Resources-Divelon of Water RmatinIM .Revised Melo*2913