GW1--03731_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD For I)acntalUscONLY:
This form can be usod for single or multiple wells I
1.Well Contractor Information:
14.WATER ZONES
Brian Ewing MOM TO DESCRIPTION
WCII Cotatacax Name h. ft.
4240-B ft. ft.
NC Well Contractor I:cnifriatton NumberIS.OUTER CASING(Tor muNi-eaml wells)OR 1.IN1R of applicable)
IntOM TO Dt111rTFR TNIt'KNtss VsTrItl sl
SAEDACCO rt. ft. ht.
c'omp;uis Name IL INNER CASING OR 11 IING tje.therral dined-kepi
FROM TO Dt1METER THICKNESS st%TERRE
2.Well Constriction Permit M: R. R. is.
List all apphr able wrl permits(i.e.County.State,Variance,*Verbal er•., ---•---____�
R. ft. in.
3.Wen t'ne(cheek sell use): 17.SCREEN
Wafer Supply Well: PHOM TO DtAMETER SLOT S171 THICK Rims MATP.Iual.
IK
❑Agrsoultural UMlmkipalrPirblic t4 is
DGeothennal(Hcatinft n to.gtCooling Shcppls l I1Resddcntial WaterStnpph nsitlglel i 1
OindustrialiConunercial II IResidential Water Supph ishared) 1R0111OtTT
rtOM TO MATERILL. EMMACEMENT METHOD a AMOUNT
❑Irngaton pt. rt.
Non-Water Suppl}Well:
ft. ft.
❑Monttonni ❑Rccovrn ,
Iejertittn Well: n. ft.
❑Aquifer Recharge ❑Groundwater Rcmcdiation tt.SANIMILAVEL PACK Of applIc tile) --
i I*4)M TO MITERLII. EMPI.1t 1MFNT MITHOn
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stommatcr Drainage ft G.
❑Expcnmcatal Technology ❑Subsidence Control
❑Geothermal(Closed Lao 1 ❑Trxtt S.DRILLING LOG titledaddilunal sheer if necc,csan I
p roost I VD j IF.CRIPTION,seler,l..w..•..,.,.ei...I.,,pr.3....e,ete.i
❑Geothemwl tHeating/Cooling Return) KlOthe:r texplain midis 021 Remits) h' n.
h ft. s. a EL)
1.Date Welts)Completed: 4-17-24 WwenIDt11P-B-2-26 (EVENS) ft. R. - �.,a`_Z
5a.Will Location: R. n. JUN 9 r 2024
Rays Grocery R. ft.
trfarT. Pt11rrr�lalli`? llatit
Fs:diry Or.w Name Faetlnl ID*of appllcabk► ^ f
Doi Cif 104
1674 E. Main St., Sylva, NC, 28779 — II ft.
PI,Sical Addles Cin.and zip — —
2l.REMARKS
Jackson DPT INSITU INJECTION; INTERVALS 6-12'
Comm Parcel Idilalf/Calu.t1 No 'PIN'
5h.latitude and Longitude in degr csiminutes/secnnds or decimal rlegrmc: 22.Certification:
pi via la ld one hi long n Sall"ncl:nl I
N W Brian Ewing 5/8/2024
`
S` _of Certified Well C<nr,,. Dale
6.Ise tare)the wdlls): OPennanent ur KTempSrafy
ay signing this four.I hereto err*.that the'cribs l war(were)notertrrrered in arrordan..r
with 15A NCAC 02C.0100 or 154 NCAC 02C,0200 Well Constrscdm Swa.f.a.1,arid Alf
7.Is this a repair to an desisting well: DYes or K No ropy of chic record has been pnwidr4 to the w01 owner.
If this A a/Ylkrrr,(ill,Nat liiNlww Nrtl,oru//u.non mj.rwwn/..n tint)I.,;.Gun rh, fa,r.•I tiir
repair under IN remarks arctiern or on the hack ql this form. 23.Site diagram or additiunat well details:
You mar use the back of this page to pros ide additional cell site details or well
8.Number of wells constructed: 13 .otlsttll.hon details. 1•ou mas also attach additional pages if necessan.
for maMpk rnjerra>n or oc s-.swrer suppl,wells ONLY with the ieme r,murwra.w ,....:as"
sabinit arrr•form. SUBMITTAL INSTUCTIONS
8.Tatalwdi depth below hind surface 12 (ry,) 24a. For An Wills: Submit this form within ?ti da}s of.ompktion of nell
For multiple wens list era depthr ifdif erent teranrple-3.g2017 and?8'l0II' construction to the following-
lii.Static water level below top of casing: (D.) Division of Water Resources,Information Processing I.nit.
1617 Mad Smice('eater,Raleigh,NC I7699-1617
I I.I3,rr•ehok•diameter:2.25" fin.) 21b.for Injection Welb ONLY: hi addition to sending the form to the address in
.4a abos e. also submit a cop} of this form w ithin 3f1 days of completion of well
12.v\cit cnnstrwction method: DRIVEN cousinr.hon to the folios*,mg.
II C.auger.roan,cable.direct pusk a:I
Division of Water Resources.Underground Injection Central Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 21699-1636
21c.For Water Supply A Injection Wells:
13a.Yield repeal Method of lest:
Also submit one cops ul chi, loom within to dassof completion of
131,_Disinfection ripe: A te; well conswction to the counts health dcpanrnc t of the camas where
constructed
F.,nu ow-I Nonh Cataluna Ucpunntnt of Ern lrowrrru add Natural Rcsuwccs Dn.non of Water Rtsotro6 no dud:tRust 1011