GW1--03732_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD For framed DiuONLY:
This form can be used for single or multiple hells
1.Well Contractor Information:
14.WATER ZONES
Brian Ewing Mom to j DF9e RIPI ION
Well Contractor Nam: It. ft.
4240-B ft. ft'
NC Well Contractor fenifrcation Number 11,OUTER CASING true Wahl cysevl wells)OR LINER(if a�ReaNa)
mOM . TO DIiMETER THICKNESS I MATERIAL
SAEDACCO II. , n. in.
t an4'ang Name le.INNER CASING OR TUBINGt;Ls.IIhermler.d•ho6)
r FROM TO IM%%IF.TER THICKNESS M.%TERRI_
1.Weil Construetiin Pent*.1: ft fl. IL
List itl applicable well permits it.County.Star,Paria,y r,bger0'at err.! .--,
R. ' fl. _ it.
3.Well Use(clack wdI Msel: 19.tiCRIC[N
Wider Supply Well: nom tO DIAMETER %ter sirs _I THI('iNMS M'anti AI.
dAgricultu I_ral 'Municipal+Public ft. ft. is,_-
DGeathennal(Heating/Cooling Su It I I IRcsidcntial WaferR. ft in
pp Supply(single) _
OhldustriallCommercial I'Residential Water Supply(shared) IL?"
IRON TO M.iTERE+tI.-----. EMPLACEMENT METHOD t AMOUNT
❑Iripatron ft. ft
Nos-Water Supply Well:
-
ft. ft.
❑Monitonng ❑Recovey -
iejection Well: R. n
❑Aquifer Recharge OGrnundwater Remediation It SAND!IGRAVRL PACK OF applicable)
mow TO MATFRI'A. tMM AITATINT METHOD
°Aquifer Storage and Recoven ❑Salinity Hamer R. ft.
❑Aquifer Test OStormwater Drainage ft. ft.
R.
OENpenmental Tochaolog ❑Subsidence Control
2t DRILUNG LOG tinsel additional sheets if necessar,I
❑Geottenmd(Closed Loop) ❑Tracer FROM TO t scku'rION i(,.br,l,pr.lnc..,u,i5mth ttpt,aria irt,nt.i
❑Geotlennal(Hewing/Cooling Return) ®Ot11er te'plair under 021 Remad.sl ft
R. R. a' /,I
4.Date W'ell(s)Completed: 4-17-24 wen ID.IP-A-1-25 (ODDS) n R. 4 '%L.`l I- fit'/
5a.Well Location: It� JUN 9 ' 2024
Rays Grocery ti. f.
Fa:tits•Ch;net Name Facilih IDN(if a iplicablet .,,,
n. ft. lax A;gii41.. -'J l.;g gilt
1674 E. Main St., Sylva, NC, 28779 — II cl ,
Ph>steal Address fin.and Zip rii.RE.M kRk,
Jackson DPT INSITU INJECTION; INTERVALS 7-13'
Camay harccl ldnnnfuc.,tioo No !PIN'
5h.Latitude and Longitude in degrees/minutes/seconds to'decimal degrees: 22.cer-tification:
(d hell fk:Isl w latlong is sullicneiill
Ts W Brian Ewing 5/8/2024
Signature of Certified Well Court I.': 1 x
6.Is(ere)the wills) ❑Permanent or B Templ►rar}' 1fs signing this Bonn.1 herebt.certify that the aell's0 rat loner cr,artnieted in arotdamt
with 154 NCAC 02C.010)or 154 NC.4C(CC.0200 Well Construction Sarndemb awl thou u
7.Is this a repair to an existing Is ell: :Iles or K NO copy of whir wont has been pmwirled to the sell owner.
if this is a repair.fill ow ta„NM n rfr,(MA3,1111 11.0 oliot ly:rl"i,,oj,'tpiant the'tMirare of thr
repair anderl21 remade.eels,or on the hack of thix form. 23.Site diagram or additional well details:
You mar use the bark of ttlio p<Ige lu pntt ode additional well site details or well
8.Number of wells t'onatrutted: 13 consiniction details. You mas also attach additional pages if Itecessan.
for maltfple irtitx'7kNt Of N,NI-MWtet lapplt wells ONLY with the seine 1'/tnlrrl wrkMf t,:M<(„
submit one fano. SUBMITTAL INSTUCTIONS
4.Total wdl depth below lard surface 13 (rt,l 24a. Far AN Wells: Submit this fame within it) dais of completion of well
For multiple sells lift all depths if d((feeent letpmple-3.'20O'Ind 20100') constnictian to the following
10.Static water kid below tttp of casing: (ft.) Division of Water Resources,Information Processing lNoll.
ifwtime Irtel it tihuir,ns, : :,•.• . 1617 Mail Service Ccater.Raleigh.NC 27699-1617
11.Borehole diameter:2.25" (ia,) 2-lb.For Inieetios Welt ONLY: In addition to sending the font'to the address in
14aabove. also submit a cop} of this form within 'IQ days of completion of well
12.Well coeslrection method: DRIVEN construction to the following.
lie.auger.ratan..cable.direct push etc.)
Division of Water Resources.Underground injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699-1636
24c.For Water Supple s.Injection Wells:
lie.Yitill tontl Method o/1pk
Also submit one copy of this funs within to days of completion of
lib.Disinfection 1- pc:. Amount:— well constmction to the county hcahh department of the colon where
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consmicled
Form GW-L Nonh Carolina Dgxsnnretu of Ern atomism and Natural Resources-Diletioo of Water Reroutes Ret ised Atgeat±011