GW1--02645_Well Construction - GW1_20240501

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•• WELL CONSTRUCTION RECORDFor ftgerunlUscONLY:
• This forincan bc•uscd for:single ar multipk wells
➢.Wilt Contractor'lnforniation:
-;t1:WAtERZONES- . . .
' Brian.Ewing . tmodt - ' TO 'DESCRIPTION
' Well CottlrtaotName ft, ft.. I'
4240-B . . . fL ft.
• NC Well Contractor Certification Mulled' - ' . tS.OUTER CASING(farisutti-cisettwtt1)OMtINER(if np'ueahk):• -
. . • . 61ioM To :. DIAMETER.I THICKNESS• MATERIAL•
' SAEDACCO • - .IL, ft.• - lo- - -
Coner:ntyNotate '. t6:INNER CASING'OR:TUBING(ggo(bermalelosed-loon)
• .'PROM TO DL41IETER. . TuicKNESS MATERIAL -
2.Well Construction Peruit#: 0 ft, 20 •• ft 1" 'dd SCH-40 ' PVC
1.4r Rl1 nppr?imble tf prneils,(in.County.S:ate,•Uaiiamrr,TiVal en or..) .
R,. ft. - •.
in,, .
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3.Wel1.Use(checkvlcll u"e): I?SCREEN •
Water Supply Well• mRost. , TO •DtAMEThR SLOTSIEE. TRIMNESS I MATERIAL.. . ' •
0Agticultutal DMunicip:tl/Public 20 ft. i 30 ft. 1" AIL' !010' SCH-40. PVC
OGeotltemtat(Heating/Cooling Supply) , I:Residential _Water Supply(single) it' I • ft. in
®iudusthal/Cornniercial - ®Residential Water Su sllated) ':tP GROAT .. •
Supply :DM. ' TO . ' - •MATERIAL '. EMPLACEMI TT.\IE OOD&AMOUNT
❑lrripatian ' ft. R. • 1
• Ntin-WaterSupnty Wolk
6Dhtenitoring pRccoyety ' .R. • R .
InJecllon'Wd(l: . . - n, - fL . -
. ClAgnifcr ici Barge DcJroundisaler Rciucdiatian • 't9 SANDIGRAVEL PACK(if Eittdb:abIt) - - . . .-, . - . •
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• VI4O I - ' TO MATKRLU. L ' • ttsIPLACKMF.NT METHOD '
I7Aquifcr-Stotngc and Recovery ' ❑Salinity Battier 18 f,. 30 ft. FILTER SAND # 2
. ❑Annifci-tfcst • 17Stormrw'aterDraina
•CJlfapctfmcnlal Tichnologp f7Stibsidencc Control - . . .
' 20 DRILLING'LOG(attach additional slices lrnecessnn•t •
❑Geothetival'(ClosedLoop) . . . ElTr.icer .rnor. . 70 DESCRIPTION(trobr.t.antncewwll'ntcktsist:urain rife.(tea
❑Geotlieinral(Heatiiig(Caoliug Return) • ❑tltlter(eaplaitt Muter(2I Rettiatks) .0 ,fL 5' fL. FILL SILT AND SAND
5 ' 'ft.• 15 • it: SILT CLAY-MOIST ' '
4.Date Welt(s)Conipleted:'4-1'24 Well IDi/TMW-1. 15 `ft, 20 ft SILT CLAY MOIST TO WET
5a.Well Location: ' . 20 ,fL 30 fi.. SANDY SILT/SAPROLITE/PWR ,
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• Four Points 76 ' ft. ft, '
. FadilityiOir'ocrNante • Facility ID.t(if-applicable) .. . •R. - ft. •
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1702.Hickory Grove Rd., Gastonia, NC ., 28056 It. ft.. ~ L.. r,.i•`•'` ~� '1
. . P1• ry'3ical Address City.and Zip'' a2 t:R4111At2GS •
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Gaston • • . . •. BENTONITE SEAL 16 TO 18' _ I , MAY V 1 COI4.
Cowly •lnreel hicnlifieaIion No,(PIN) • -.
. j lt•..e:;, :.'.-:: br-i-.rrti J, Up..7. .
• - • 5b.Latitiidc'alid Longitudein dcgrecsfminutcs/seconds ayItticimal degree ,_•Ccrtifcaditu:, I' L`•Pa C i 2 QC)
(1foCl)field,ow 4ttioug iR suffykid) ; '
. N W Brla.nEwing, • 4/5/2024
• ' '' 'SlgiutureofCertified-WellConLxtar: ' _ .Dale
• 6.IS.(ire)the w'ell(s):1❑Permanent.. .ter $ITemporatl' • •itysigning thin fanny!irer-by crag).!ha*oral's)ma(IYrel❑!nrrrnruled In encrarlmice
' ;fat 1511 NCAC 02C.0100 or ISAA NCAC 02C..02P,0 Well Construet(wr Standards and Harr it
7.Ix this a repair to ail eristin);my'ell: • rilYcv or 11;No soprof this record lrrt berryproi'irkd rorka null miner. '
If Ws'is a repair:fill oatkrouww well carurnicricn lnfarmrrlmt and explain the nnnrre of the '
relurirdrdsrB21 rrnutrlLi sm-:iuo or run the balk of thus fount.. 23.Site.diry rim or additional well diiait.s:
. You Luny use die back of this page tu.pros ide.additional welt site details or sselt
•- 8.Number of wells constructed: 1 • eotisttuctiandetails, You tray alto attach additional'pages if necessary.
Forennlalple l.I feeilon or erri-ewer tin)*wells ONLY trial die same corstructlorr,yori can
' sabnritane prin. SUBMITTAL iNSTUCTiONS.
9.Total well depth hew land surface: 30 (pl.) 2-Ia. For All Wells: Submit this form tvitliin-30 days of completion of Well
-For mrilslpleivelr!istotl depths ifdifferent(cxamplr-3@20t0arull@Miry consiniclionlo the following; - • i'• - •
la.Static water level below tap of casing: ' - '-(tit.) Dt ivion of Water Resauncs;Infortiration Processing Unit, .
• • 'triter lovel lsnbove casino:ase"+" 161714Iail Sen'ice Center;R Ilcagh,NC 2769!)1617 .
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11.Borehole diameter:2.25" •(in.) - • • 24b.Fotkoka _Wcas ONLY: in addition to sending the form to the address-in •
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• 24a above.also.submit a copy of this fount within 30 days'of-cotnpletiou•of well
12.1VeIl oonsnstctimt method:DRIVEN .• •- .' cotishuctiou to the following: . ,
- (Lc.auger.rotary,table,dheci posit etc.). '
' 'DMA it of Water Resources;Underground Injection Control Program;
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FOR WATER SUPPLY WELLS ONLY: -• 11636 Mail Service Center.Riilcigh,NC27699-1636
13a Wield(gym) Method of test: 2,4c'For-Water Supply&tnjcctton Weirs:
Also submit one copy of this faim within 30,days of completion of
131t.Disinfection type: • • - • Amount: well i.onstniction to the county health department of the.county where
• constructed,
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Fann GW.L North Carolina D0.^psiyiret of Eatitatmic•-u acid Natural Resources-Divi lonofWatciRt • Reilsed Atgus#ro13 1
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