GW1--03623_Well Construction - GW1_20240613

WELL CONSTRUCTION RECORD For[menial Ilse ONLY:
This(corium be used for siagk or niuhipk tsells
1.Well Contractor Information:
li.WATER ZONE;
Brian Ewing I nOM TO D►SCRI/T1OY
W c11 Contractor Na„a ft. ft.
4240-B
ft. R. '
NC Well Contractor Certification Number 1S.OUTER CASING(fan euNi-cased sells)OR LINER ill apaIlealliki
!Rom TO DU MT TER TNtCksr.S l %Is1TRR i
SAEDACCO ft. ft. is.
Compost Name its INNER CASING ORTI't!NG phermaleland-hwyr)
n1OSI TO - rDIAMETER Tun A'EAS i MA IT RISI--
2.Will Construction Permit 0: 0 ft. 5 ft. 2 IL SCH-40 I PVC
Lu all appli,-able urn penal',(i.e.Count Starr.t'eriumr 111'KOdI el..i ----._ —,'
R. ft. is
3.Well 1 sr-{-heek well use': 17.SCREEN
Water Suppl SS all: etas) TO DIAMETER sun.{) , THIEKNTs MATERI I.
UAgricultural OMimicipal/Public 5 R. 15 R 2 ill. O10 SCH-40 PVC
OGeothermal(Heating/Cooling1 Supply) OResidcntial WaterSttpph (singlet ry' ft. in.
Olndustrial/Conunercial i!Residential Water Supply(shared) `1IGMROQt To MATERLAL EMPLACEMENT AMOUNTMETHOD 1, •
❑Imt:attoo ft. ft.
Ton-Water Supply Well: R. R.
El Mormon rig ❑R .oven _
injection Well: II. ft.
°Aquifer Recharge OGmundn;atcr Remediarion 19.SAND/GRAVEL PACK Of taiRkahlel
FROM ' TO MATERUN. VMM.s(EMEVT METHOD
°Aquifer Storage and Rctimcn ❑Salinity Barnet 3 ft. 15 R. FILTER SAND II 2
°Aquifer Test ❑Slormiater Drainage —R. ft.
DEspcnmcnlal Technoiogs ❑Subsidence Control
2a.DRILUNG LOG(attach additional sheets if rrcccssan i
OGeothennal(Closed Loop' ❑Tracer Plum TO DESCRIPTION t.wbr,width(..,rdl•r.w.opt.pawn... at I
DGeothemnal(Heating-Cooline Returns DOther(explain under a2I Remarks) 0 R. 5 ft. FILL SILT AND SAND
5 ry. 10 ft. WET SANDY SILT
4.Date Well(s)Completed: 5-16-24 Well IDIrMW-3R 10 ft. 15 rt. WET SILTY SAND
Si.Well Location:
Ward Citqo It. R. 4.'": '°' 1-:!'
Fa:ilit OwtrrName Facilul iDa(if apple:161c' ,- h. •
rn.
aJUN 12014
10236 W R Latham St., Clarkson, NC , 28433 _ to. rn
Plnsicah Address.City.and Zip 21.REMARKS rifOTA G to P.r..einli,$Upl
Bladan BENTONITE SEAL 3 TO 5' DnriCi11 4
Gluts+ Parcel klentifmatioa No I/1N,
Sh. Latitude and Longitude in degreesintinales:seconds or decimal degrees: 22.(.eitifrration:
it c..J.b>:Id iar:la;Ina:2 r.strllihr:Il
W Brian Ewing 5/31/2024
Signatum of Certified W'c:1 I , ! Date
6.b tare)the*elks i: X Peimancnt or :Temporary
lb Craning title font.1 hereby certify that the warns!war(semi centime-led in accordance,
with!SA NCAC 02C AIR)or I SA NCAC 02C.0200 Well Catarrh(non Standards and rho:a
7.b this a repair to an existing*ell: ❑Yes or No ropy((this record has!seen provided to the WWI owner.
if this u a repair,fill nisi known melt•"nano tvaa mfonaautan am!a rplotn the mane of rhr
repair underl3!remarks sea liar or an the hack of this form. 23.Site diagram or additional N ell details:
You mat use the back of this page to pros ide additional well sue details or well
8.Number of wept coosttxted: 1 construction details. You ittas also attach additional pages if Inecessan.
For malttpk otjecnon or two-wrarrr,wpplt wells ONLY with the taint runbrractierl nos rot
sterna cne font. SI'BM ITTAL iNSTUCTIONS
9.Total well depots bebw land surface: 15 fR.) Ito. For All Wells: Subsist this font union ran dins of completion of nell
For mairrpk urns list all depths ifdtfferen:terantp(.- r61,21Ai'aml 26p law)'s construction to the follotsin g
ltl.Static water les el helms top of easing: (ft.) Division of Water Resources,information Processing t nit.
If..,or,late).,01111 r,f/Stn1( au- . 1617 Mail Service Center,Raleigh,N('27699-1617
I I.Borehole diameter.8•25" (in.) 24b.for Injl,rtioa Wells ONLY: In addition to sending the form to the address in
24aabote. also submit a copy of this form tiithin S0 dins of completion of nell
12.Well construction method: BORED construction to the folloss nig.
i c auger.rrian.cable.direct push.etc i
Disi+inn of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail'tees ice l enter.Raleigh.NC 2'694-1h36
24e.For N Ater Nuppls &Injectiia Wells:
13a.l icht(rpm) Method of test:
- Also submit one col) of this form stithnl 10 da)s of completion of
131).Disinfection'oils': Amount: well constriction to the count) health health department of the count)*hen
constructed
I ,,.. 6., North Carolina Deptinntem of Ein rnoruricra and Natural Resources-Do non of Water Remoras Ro iced.August 20 1 t