GW1--03734_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD Foe!mental Use ONLY:
The form can he Used for sinjk or multiple sells
I.Well Contractor Information:
I I4.WATIR ZONES
Brian Ewing PROM 10 DESCRIPTION
Well Cottr.•E lnr Name Lft. ft.
4240-B
ft, ft.
NC Well Contractor Cenific Lion Number 15,OUTER CASING(for meMi cy,rd...Ohl OR l#IIRR(If atDtiLaNtr)
PROM 1 r0 DI%SIFTFR THICKNESS MATERIAL.
SAEDACCO ft. i ft. is.
('ompain Name I .INNER CASING OR TUBING(JteIbersal clesed-lay(
IROM �TO DLSMETER THICKNESS MATERIAL
2.Well CoattrTlction Permit th ft. ft. in:
Lill all apple able sripertmmit fi-r.C•ohnty ,Starr,Varia,err.Illertialt er.0
O.
3.Well Vie(check well Rae): 17.SCREEN
Wager Supply Well: roost TO DIAVWTPA MOTS17/ TITICTOOM MArnr't.
❑Agricultural I_lMunicipal;Public ft. ft lit
❑Geothermal 1llealing,Cooling Suppis t I Ikesideti al WaterStpph (single) ft. ft. ia•�
❑IndlrstriatfCommacial 1 Residential Water Supply(stored) 1e' s4� --,.PROM TO M.+ITERLU EMPIACEMENT METHOD a.AMOUNT
❑Irri)lation ft. ft.
Non-Water Supply Well: --
❑Monitonng ❑Recovers Injection Well:Well: n. (L
❑Aquifer Recharge riCimundsatcrRcntcdi:Rion Is.SANDlGRAVRL PACK INaliPticit1r*
PROM To slsr►insl tMM.a(FMFNrMrTnon
❑Aquifer Storage and Rumen' [-Natinin Hamer ft, R.
❑Aquifer Test ❑Slonrns:ucr Drainage h, h.
❑Experimcafal Technology ❑tiuhsidettcc Coarol _
❑Geothtermtd(Closed Loup i O'Tracrt S.DRILLING LOG tatted additional sheets if accessan t
p PROM TO DESCRIPTION,tnler,hard...,,,aukn.ri,npr.Itr.i..ve.Oil I
❑Geothermal IHeahngK•000ling Return) IN Other(explain under 921 Remarks) h. n.
R. fL ,...\.t...a'VEj
4.Date woks,Completed: 4-16-24 Weil ID.IP-A-2-26 (EVENS)
IL fL
5a.Well L JUN 2 1 2024Location: R. ft. '
Rays Grocery h. IL (bfsltltrdskret r-Rr^4ya:./t Unit
Fa it nn,ths net Name Falcdils i13N(if epplicablci bifieal()QI
1674 E. Main St., Sylva, NC, 28779 n. it.
nosiest Adbess.City_and Zip 21.REMARKS
Jackson DPT INSITU INJECTION; INTERVALS 6-12'
t'outt. Parcel Id stificaiiun No IPIN I
Sb.Latitude and Longitude in degrecsimioutcs/sccnnds or decimal degrees: 22.certification:
(ri is LI:1).ld one La long r.,Wlici:nm
W Brian Ewing 5/8/2024
Simian of Certified Well Cora, I Crate
6.is(are)the ssellisl: :JPermancnt ur X Temporary
M signing this font,.I hereby certify rem the Mrl!(xt sour Issrrel L mrmetod in accordance-
with 154 NCAC 02C.O/fk)or 1 SA NCAC 02C.0200 Well Coxstrwrtion Standards and rho:a
7.h this a repair to an existing well: .1.‘es or IC No ropy of Mit record kw been pmv4ed,o Ore Nell owner.
if MO n 0 ttphar,fill"at(mown,.ell,towns.to,,,a,)rmgiro.,an41.'1'iaol the norare of the
repair under 721 rrmarkt.O S-aiart or..,the hart of this form. 23.Site diagram or additional well details:
You nun use the back of this page to pros tele additional well site details or well
8.Number of wells constructed(: 13 construction details. You may also attach additional pages if iso essan.
Fur malrtple arl(errant a,NMI-water►uppls well:ONLY.tarp the same cemWwerion vets.an
.abmirane forwa. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface 12 (ff,) 246. For Al Wills: Submit this form within 710 dacs of completion of sell
For.tthlpte well:II:,all depths if dflirq'au fr,ras'pfi-t02O0'and 2frran constniction to the following-
le.Static water level below hip of casing: (fq,) Division of Water Resources.Information Processing Init.
e,,,;,,,.:7l•'I t vh..rr.aswk ,,.r '. 1617 Mail tim-ice('cater.Raleigh.NC 27699-1617
t I.IL„rehok diameter:2.25" (IL) 24h.fur IniLstion Welb ONLY: In addition to sending the fora to the address in
24a above. also submit a cope of this form within 30 La's of completion of sell
12.N ell eonslrwction method:DRIVEN con sins:ion to the following.
tic auger.recto.cable.direct push etc 1
Disislon of Water Resources.timicrKrnund lnjrctiun Centro Program,
FOR WATER SUPPLY WELLS ONLY': 1636 Mail Scrs ice I.enter.Raleigh,NC 2'hO')-Io34,
13a.1 iold(glom xt.-rh.,d.it t.'.t:
14e.For\(Ater Nuptilt 4 injection Wells:
Also submit one cop? of Ibis tom! isithm to dn s of completion of
136.Disinfection is pe: \m.nuan: well construction to the cotmn health deponu►na of the Counts where
consinicted
I ,,. 'a-i Non Carolina Divan:nem of Eat itottnrtu old Natural Resources-Pit aeon of Waist Rtwtrces Res tied Atopst 2011