GW1--03605_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD Forl,tenuil tire OM N.
This form can be used for single or ntuhink Hells
1.Well Contractor Information:
14.WATS*ZONIS
Brian Ewing PttOM TO ) DF.SCRIPI1t1N
N'cll('oraeuhtt Name
ft. ft.
ft. ft.
4240-B
NC Well Contractor Certification Nttit)ber 15.OUTER CASING nor multi-eased wetly!OR LINER of aD tkabk)
IRON To DtiMITER I TNN'KNrYS MiTtNIkl
SAEDACCO ft. fr. it. -
Comp:e)Name _16.INNER CASING OR11 Ftn(, ..nhricnal chord-i,,ijft
iROM ' TO ,I.." 1l it TIIICKNEs.i MAtERMI,
2.Well Construction Permit fl: 0 ft, 8 ft. •1" to SCH-40 PVC
tar all appiicnble well permits(ce.County,Slam,Variance.61's-barl rrr.! — _�..__... - -,
ft. rt. 1 is
3.Well Fite(cheek well use): 17.SCREEN
Water Supply Well: PROM TO DIAMETER SIDI ten TN1CrcNtss J MA trill AI.
ElAgftcultttal OMtlnicipal/Public 8 R. 23 ft. 1 is. .010 SCH 40 I PVC
OGeothennal IHeating.Cooling Supply) OResidential Water Supply(single) ft' ft' t.
Ohldnstrial/Coinmcrcial OResidential Water Supply Istured) 1i' c(ROVI
ItfIOM TO MATERIAL EMPLAI f\I INT Mr 1110D A..UIDI_VI
❑hrigation ft. ft.
Non-Water Supply Well: ft ft,
®Monitoring ❑kccoven
injection Well: ft. n.
O Aquifer Recharge ❑Groundwater Rentedi:pion If.SA.NDIGRAVtL PACK lid aitilcr k)
MOM TO NI arltglst. P:MPI..t*Au:NTMrTHOn
(]Aquifer Storage and Recovery ❑Salinity Ramer 6 R. 23 ft. FILTER SAND # 2
IDAquifer Test ❑Stortmvatcr Drainage
—
IN. ft.
❑Experimental Technology. ❑Subsiderrce Control
20.DRILLING LAG tallact additional streets if*tertian)
❑Geothermal(Closed Loop) ❑Tracer non TO Desc-Rnno',tnbr,r.Mnea,wilVnIck opt,Rani.woe,ck.l
❑Geothermal(Heating/Cooling Return) :Other(explain under 421 Remadts) 0 ft. 5 IL FILL SILT AND SAND
5 ft. 15 ft. SILT CLAY MOIST
4.Date Well(tl)Completed: 5-15-24 Weil iDoTMW-5 15 n. 20 t1 WET SILTY SAND
5a.Well Location: 20 ft, 23 ft, WET SILTY SAND/CLAY
s*....
W. Cumberland St. PCE Site ft. n. { %`Le !s ! ij
Facility'Ou ncr Name FacilityMO inapplicable) n. 1— ft ��A, v C
1200 West Cumberland St., Dunn, NC , 28334 n. n. f' 1 �4 Z014
Plnsical Address_Cin.and Zip I TI.RI_M tRKN lnfer
Harnett BENTONITE SEAL 4 to 6' ar�t4rl .Airit•:A�;J,R,
Count, Parcel ldcittittc:ifion No (PIN)
Sb.Latitude and Longitude in degiees/minutes/scennds or decimal dtgrtYs: 32 Certification:
,;it it,11 licld.mil IaCloitg is.sidlic¢ilV
N W Brianl�Ewiing 5/30/2024
Signatuot of Certified
6.6lare)the twills): :_1Permenent or E1Temporat3' g\signing this M'.I hereby certify that the wrll(rl hay(were)committed in a cordmair
with l SA NCAC 02C.01fkt or 15A.NCAC 02C.0200 Weil Conatnottion Standards and that a
7.Is this a repair to an esisting Nell: Olin or 10 No ropy of this rrroni has hers provided to the aril owner.
If this is a,eruct fill,..0:n,,,.a i•r11,,it,a,u,n.m inform-awn and a rplaht the moire of the
repair under 021 rroiark.amnion or on the hack of this fnr,n. 23.Site diagram or additional well details:
You may use the buds.of this page to provide additional well site details or well
8.Number of welts vviastnscted: 1 construction details. You may also attach additional pages if lecessan.
For mahtple injerrton w rout-sonar swish wells ONLY owls rile saner construction'.you ran
submit one fors. SI?RMITTAL INSTUCTiONS
9.Total well depth below lewd surfaem 23 (h.) 2.1a. For AB Wells: Subnit this farm within 30 days of completion of well
For main*wells list all depths if different frsaenpfr-1@200'and 2€1001 constriction to the following-
le.Stade water level below top of casing: ((y,) Division of Water Resources,Information Processing Unit,
tf WON.,kiwi is abase sastns.a,e•"+" 1617 Mail Service('enter,Raleigh,NC 2769'1-1617
11.Borehole diameter:2.23" (IL) 2-lb.For Nicene*Weib ONLY: In addition to sending the fofm to die address in
24a abut c. also submit a copy of this form within 30 days of completion of well
12.Well soostroction nictitnd: DRIVEN constmrttun to the following.
(i e.anger.raise.cable.direct F.,, ..
Division of Water Resources.Underground injection Control Program,
FOR WATER SUPPLY WELLS ONI 1: 1636 Mail Service Center.Raleigh.NC 27699-1636
tic.For 1Fater Supply S.Injection Welk:
13a.Yield mom) Method of test:
Also submit one copy of this form within a() daps of completion of
13b.Dixinftrton type: Amount well constniction to the county health department of the count where
constructed
Form OW-I North Carolina Department of Ern itoiutent and Natural Resources-Division of Want Rmoiiem kit iced August 2011