GW1--02252_Well Construction - GW1_20240409

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WELL CONSTRUCTION'RECORD •
• : PO rIm etnal
• . This form eta!boilod for.single at multiple wells: . . •
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I.Welt ContraCtor Informatiott:
• . • . • 'TT:WATER ZONES-. . . . , . • • .
Brian,Ewing , .. . . , , . . . . PROM 10 DESCRIPTION
- Well Cnntractot Nante . . ft. • •I .
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ft. it: • - • •,
• - 4240-B . . • •. • • . I. . - •
. •• " ‘TIS:'OUTER CASING thir mutt kasedWctIsli ORLINER(If ticahlel, ;
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•. ' • - NC Well Connacht Cca ificatioiNiniker ' . '
FROM TO - ' DIAMETER,i vincimss- • STATERTAL• 1
• . • , . .ft..• . ,. ft.. iti.• .
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. SAEDACCO • • • • • •
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Optically Krone • . - - 16.`INNER CASING OR TURING(geolberinal dosed-limp) •' '
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•FROM TO DIAMETER , THICKNESS IVATERIAL .,, •
' 2.Well Conttructiiin Permit 0: . . . . . . , . . .-. --R. . - ft. • • *hi. - . .
- : Liu uttoRdieot/te wejlIpenuits.0:e.county:Stale;.Variwtcs.l'orectiart,etc..P . . - •
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. . - 3.Well'Use(cited:well uce): - .
rnSCIIIEEN , . . •' •
• • Water Supply Well: s . •. • . FRO'I . TO • .•orvatrtnit •SLOT SIZE -macs MtS. r MATERIAL •. •
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• • CI Agricultural • - -. InMuniCipal/Public • " ft. :ft.• . •
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. • InGeothennal(lleatingteoting Supply), CIReidential Water Supply(single) .'ft' . ft• .- . . .
'.. . . - Mindusttial/Conintercial - ;
. CIResidential Water Supply(shared) • '-rnittloGNat°UT: T6 .',,ATEREAL EM
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PLACEMENT,METHOD.SI&MOUNT ..
13Irtieation . ' • ' - • . 'ft: • ' -
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Nou-WateeSuppki•Welt:. - ' -' ,. • • • : • . -. . . . . . •.
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ft.. 0. .
] , 13.Monitoriog • . ' • . - •PRecoyety ' .. ••. .. :. ' • .
- - InJection.Well:. •• . -• • . - . ,..k., - , •tt• .-I:, -• •
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. • . 0 Aquifer Recharge • " EIGioundwaicr Remciliation - . ,/9:SAND/GRAVELPACK(if aitAalde'r•
' - " 'FROM' " • TO• MATERLAI,, : EMpl_.‘CTAIENT METHon
- • 13Annifer Storage.and 11cCovety ' -
. l:ISalioity 13.-.(rti pi. . • -
• - , R. ft.. - I
• 0 Anvilfey Test: . 1:1Sormwatet --•
i Drainage'• ' . .
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-. . . . . ft . .
• • •. • . . DExpehretnental Technolo OSibidene Cotag - • .-• • :20..,D.P_J LIIN.G L.OG.(tachadditionasheeti if tccessarvI
3Geotnal(Closed Loot) • bTracer ..
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-- • • - . ' .FROM 10 DESCRIPTION RI)biAlattIlleVii 11111MItli I,retiOlill tkiit.(ft.}' '
1:1Geolltenual(Heatintkoding Remit') ' Mother(explain untier•ialReniads) .0 'ft. -18. ft, FILL SILT.AND SAND '_
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- • - ' 15 it.. 20 . ft. SILT CLAY MOIST • • ' -• '•
4.Pate Wetl(s)Complacti: 3-14-24 • .•Writ MAI 12-1715 (Odds) •
. . 20 . :ft, 30. ft,.. .SILT•CLAY:MOIST•TO WET '.
- . • 54.Well',oration: .. . • •
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New Hope Laundry • R. • . • 1,',--..-"'l-,•f; .;',..en,tii.•,.i ,.•,„,„
, •,.. N.,‘-...,..t.44.ri.....: ' '1;1 'I • 41,9 ' • •
. Facility,ThiverNamo " Facility 11).!"(icapplimble) —
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' 2100.South New Hope Rd., Gastonia, NC,. 28054 ' , ' • • . . .ft. . , „:. . . ,. . Aiiti 0r.9.2C124 .
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. . . . . Pk,-Steal Address.City.aid Zip- :21:REhlARKs.
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. •• Gaston , • ,. . ` . : „ .Insitu Injections Boss 200•litf,.::ii';.:::....:o Pt..... ';'-'.a1-:-.,',13 1...kitft- •
' • . • D"10:70C; • ' '
Pared l 11.101.1ifiC411011 No,(PIN) . • • ; • •
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• Sh.li.atittide and Longitude in degrees/minutes/seconds or decimal degrees' '. .. .
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• (truert kid,ous-tatnotiiiisurricicio •• . • • • •, • - • '' 22.CcieatIon:-- : '• ' • - '
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i a n Ewing . , . 3/15/2024
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• • • . • . . - SIsFuEse SITCRIBcd WeicanDs0s; I • • " Dare • , '
. " &Is(are)the well(s) Ellte.rmmtent or XITemporary' . •• •
•Ili signiag,ifril fomr.I hereby errtYy that The 114(4 war fnrrej emytnrcted fitaveardanye ' '
• . . - • 'with FM NCAC 02C-.0100 or/54 NOW de.021117 Well Conitniedt Statufards and lima a
• 7,Is this a rI:Pair.tu ail txhtipsIvcilf fziw_s In, ERNI, :cciiy of Mk r•Noi-ri has EY cyt'u rovidett la Oki irelt
• I,ftttls'is a irpair,riff est Antatit will catunuctiaa itrfoyminfog aid explaht the nit rare of the ., .
repair tender OP remarks iraiin or rut the boil of sk i forts. ' ' ' -, ., • 23.Site diagram'or addirional well demits: ,. . , • •
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• •• .- . • You-ma use the back of this page to proride additional well site details or well
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• 8:Number of wells constructed: 8 • ' ' . . ... . • • constauction detai6, You may also attach additional pages ifriccesSaty.
For ntalflpfc Ialecitun or anti tatter sitppb.sellsft ONLY:with die mate construiflou.,-sziu can
• .,- ' stibmit'one form.- . •, : - SUBMITTAL INSTOCTIONS , .: ' . .
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. .. • 9.Total well depth below laud surface: 30 - . ' -. (ft.) '24a. FIsr ALL wens: Submit this•fortO within 30 days of completion of Well
• For sialtiple'welfriist ag dm&if crdiyelti(extrolpte-.7@20•0'arid 2@ WO) • . • construction to Mc follotsing: I ' - ' -
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10.Static water level below top of casing:- • 01! Division of Water Rm'm ,Information Processing Unite
)- . •-16iriMait Service Center,Raleigh,NC 2769I)-1617
limiter-level ft abate cgaitx use 4" • • .
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. • . 11.Borehole diameter:2,257 - •(in.) . . 24b.For Infection Wells ONLY: In addition to sending the form to the address in •
. . .24e abo.ve..also.submit a copy of this,form within 30 days of completion of well . .
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. ' -. 12.Well cOnstruction'Method:DRIVEN -. ' • •. . . ret1.51Mitian to the following! I.
(i.e.• auer.'re4my,cable,direct push,etc.) • •' •• . . . I •
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' . 'Division of Water Resources,Underground finjection'ContrOl Program; •
FOR WATER SUPPLY WELLS ONLY:• • • - 1636 Mail Service Ceitter.Releig14 NC 27609-1636
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24e.for-Water Supply tit Injection,Wells:
, , 13a,Yicid(gpte) - Method of test:. •. • • .
• Also'submit one copy'of thii fcimi.‘citbin 30,days of coMPletiott of
•13h.Disinfection type: _ • Amount: . wctl Construction to the cowhom. unty hcItli,department of'the.counly., , I .
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• ForesGW-1 • Noah Catalina Deparipene of Envicontirpt and Natural nominees-Ail:lin:9 of Wm&Rmaircm .Rented August 2oll
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