GW1--03604_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD For Immo►Use ONLY:
The form can be used for sinik or multiple wells
1.Well Contractor Information:
I.I.WATER ZONES
Brian Ewing FROM TO I orSCRIPTION
H'ctt COIarlerM Name ft. ft.
4240-B N. fl. i --
NC Well ColenlnorCcnifrcalan Number i IS.OUTER CASING(for oaNi-cawvl s.elbi OR LINER lif a ticrek
• FROM f TO DIAMETER T I('K\r.4 NI STTRIU
SAEDACCO rt' I rt' u'
Ih.INNERCASING I TUBING bereaiclosed-lot
(bn.p:uq Nam: jt� closed-low
PRO N t TO DIAMETER THICKNESS %I%TER_I tI ,
2.Well Construction Permit 4: 0 ft, 8 ft. 1 iI. SCH-40 PVC
List all applicable wvil permits tie.Counts. .Stair.l'anhm.r.filiation rt..t — - •
II. R. a
3.writ r.•rcheck well ese): $7.SCREEN -
WlttierSupph �1 d1: now TO WAMtTER Sint STY)' ' nrl(kSls MSTFRIAI.
LIAgn:ultuial OMwucipal/Pt►blic 8 23 ft. O10 SCH-40 PVC 1 i+•
°Geothermal(Heating;Cooling Supply) OResidential Water Supply(single) ti rt. is.
ClIndusttial/Commerrial °Residential Water Supply.(shoed/ IS'
iI054 TO NI%TERUL. ENRI.t(INTENT Nit 11101)A ty4Ot\T
❑hrigatron n, n,
Non-Water Supply Welt: 4
Ehtonttonne ❑Ra:even -
Injection Well: n. ft.
•
OAquifer Recharge ❑Groundwater Renrcdiation IV.SANDK:RA4'EL PACK(if. JL.11le)
F*QM II) NI yrERt5t. EMPt.A(?MENT Mrvuon
°Aquifer Storage and Recover ❑Salinity Harrier 6 ft. 23 rt. FILTER SAND 4 2
❑Aquifer Test ❑Stonmyirtcr Drainage —
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheers if nccessars)
OGeothennal(Closed Loop) ❑Tracer 1rROM TO DESCRIPTION.tuts,rarot.•..,..e.w-I.opt.groin wee,ass
❑Geothennal tHeamrg+Cooling Return) ❑Other IeNplain wrier 121 Remad s) 0 ft. 5 II. FILL SILT AND SAND
5 ft. 15 II. SILT CLAY MOIST
4.Date Wells)Completed: 5-14-24 Wttl IDITMW-1 15 ft, 20 ft WET SILTY SAND
5a.Well Location: 20 n. 23 it WET SILTY SAND/CLAY
W. Cumberland St. PCE Site ft. ft.
1 \ � t j/FV
Faclbt,.Oori r Name Faciliq ID#(ifapplicable) —
fl, h. V
1200 West Cumberland St., Dunn, NC 28334 it. R. JUN 1 2024
Plostcal,Addiesi Cit..and zip 21.REM ARKS _
BENTONITE SEAL 4 TO 6' IrftZrS'i3C1 7.'"'" s„a .y�rR2
Harnett D'frl,a 1i.+a
('n,ii I, P.tnci IdcnuftraUm.N. PIN
Sh.Latitude And Lungitu le in(k t!reeslminuresosecnnds or decimal degrees: 22.certification:
id well field,1,111C oat 11,11r r,sullickidl
N W Brian Ewing 5/30/2024
Signalise of Certified Well Connector Date
6.Is(are)the well(sl: '.:Permanent or 7CTemfwtrtrty gv signing this fora,!hereby certify Mar the sent's wets Inert)cantor m-k,l m accordance
with I NA NCAC 02C,0100 or I5A NCAC 02C.0200 Well Conarrnrp(u,Snindards and the:a
7.Is this a repair to an existing well: ❑Yea or EllNn core of this record has been prnridr!M the well owner.
1/;biz 11 ii rrlmir,fill vat(rrvsa0 sr11<001,171n rnnv infontaaram arul r epfain the,murare of the
repair under 021 remarks,r,ri.xi..r on the hark of this form. 23.Site diagram or additional well details:
You may use the bads of this page to pros irk additional well site details or well
8.!somber of wells constructed: 1 constluction details. You Inas also attach additional pages if necessary.
Fo. ,.nor infewom or oori-a.,; , ,unplt tolh ONLY with Mr aameemrstrucriow ve,s(a,v
tabour<me form. SUBMITTAL[NSTUCTIONS
9.Total well deli*below lewd teu'facc 23 (fy,) 24a. For All Wells: Submit this form onion 3n days of completion of well
Foe rinoWple welts lin all depots if different lexatwpfe-.1e200'and 2@ 1001 constnictton to the folloning
In.Static water Ieset bcluw top of casino _ (B.I Division of Water Resources,information Processing I nit.
(!noire lrsel n,rlbtr,amok N•F - 1617 Mail Sees-ice Crater,Raleigh,NC 27699-1617
I.Iior hnk diameter:2.25" (ia.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24a abets e. also submit a copy of this form within 10 days of completion of nell
12.Well construction method: DRIVEN construction to the folios%tug.
sI c.auger.roue.cable.direct push etc.}
Phiskrn of Water Resources.tinder•gruund Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Seri ice Center.Raleigh.NC 21699-1636
IJa Yield ILTmI Method of teat: 24c.For Water Supply &Injection Welts:
Also submit one copy of this form within 30 days of completion of
131i"hi>intiction ripe: Amount: well construction to the count health department of the count('where
_ constructed
Form GW-1 North Camhna Deportment of Em uomiw,u and Natural Resources-Diyuion of Water Rearms Res mad Argeat?t)11