GW1--03735_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD For fraen iI Use ONLY:
This form can be used for singk or moltipk sells
I.Well Contractor Information:
Is.Lau ZONES
Brian Ewing PROM TO DV!WRIPTION
Well Colmcior Name ff. ft.
n. ft.
4240-B
NC Well CafaracrorCenificalion Number15.OUTER CASING(for u►uN4-cas it wells)OR LINER tit aptlicahkt
roost i TO DIAMETER THK'KAENS M.4TTNIAI
SAEDACCO rt. ft. i..
Cullom)Nanr 1n.INNER CASING OR 11 BING 1 crt r ralelsse/•tiw)!
E110kt TO DIAMETER TRK'KNESS MATERIAL
2.Well Co/)*Than PtrmB it: RI0100715 nt. R. im
Liu all apphi-able urn permits fir.County.Si.r•Variarr.Atherton eh-.i • ------
ft. • ft. in.
3.Well Ise tchccl:well tuck • I-.S(REIN
Water Supply Nell: FirOM Itl DIAWITTR !ttATS177 T11I(1(NItRs ! at.4TRRIAI.
OAg'tcuhuml OMunicipalrPublic fe rt. ia.
OGeothetmal(Heating,Cooliog Supply) OResidential Water Stlppl (singlet n' IL in' I.
DbidttstrialiConunercial ORcsidcnaal Water Supply(Aired/ la.GUT
FROMRO TO MATERIA—`L EMPLACEMENT METHOD A AMOUNT
❑Imgatioi ft. ft.
Nan-Water Supply Well:
ft. ft.
❑Monitonop, ❑Rrcm'cn
Injection Well: ft. ft.
OAquifer Recharge CiCroundwatcr Rcmcdiatlion 19.SANDIGRAVtL PACK t1 inaBaglild
room TO MATLRIAI, RMPI.st IMi%T MFTHOO
[Aquifer Storage and Recover ❑Salinity Elamcr n ft
❑Aquifer Test ❑Siomncater Drainage
ft. n.
OExpenmental Technology ❑Subsidence Comm!
f 20.DRILLING LOG)attack additional sheets if occessars i
❑Geothemud(Closed Loop) ❑Tracer ERost TO DESCRIPTION,u.i.r,k.rdme«....a,..I.n pr.;m.o...4..or.i
n.
❑ rm Geotheal(Floating/Cooling Return) ®(hher(explain under 021 keatarl.st It
ft. ft
4.Date W'elhs)Completed: 4-24-24 Weil ID0IP-D-2-26 (EVENS)
;a.Well Location: ft. ft. . s..... tn.•a.. - v L.tr�J
Rays Grocery rt. ft. JUN 9 1 /014
Faclln)'thsncrName Factlns Iflk0ifappliiable, — _-
ft. h.
Ion
1674 E. Main St., Sylva, NC, 28779 n. ft Ift AWA•4 T am•aleg i
Plirstcal Address.CitA,and Zipj - —
.RCMARICS
Jackson DPT INSITU INJECTION; INTERVALS 6-12'
('a,trm Pastel IskIIti ii.il ion No (PINT
Sh.Latitude and longitude in dearecsiminutrslscenndsor decimal degrees: ,..(snitir:ui„n_
,t1 uili lild nne I:n 1„t112 I.,i,IILK 1ti
w Brian Ewing 5/8/2024 .
Sigrutnre of Certified Well Contractor
6.lx tare)the welts): JPermanent 'Jr 2nTempt'rar By*mins dais funs.1 hereby'ferritY rim the wen(3i miur form)[r wrtrirsmd it vitro durre
with 154 IVC.4C 02C.01(t)or 15A NC.0 me.0200 Well Construction Standards and crest s
7.is this a repair to an existing well: Yes or K No ropy oldies word has been provided rn rh.'wr1l(miter.
if All it a repair,fin bra karma,lire,.. on..,,.u,ill f,.rnIa.u1,,,and rkpk„n am'm,u.,r of to,
repair under 021 remarks.r,•ri.m or cm rhr hark of this form. 23.Site diagram or additional well details:
You Hots use the back of this page to pro%ide additional well site details or well
S.Number of welts constructed: 13 construction details. You may also attach additional pages it Ikcessars.
tor.mslrl),lr Inforran at sari-sorer nq'ph wells ONLY orb Ow sore eMaKRcifosi soy r<,n
Agamut one harm. SUBMITTAL INSTUCTIONS
9.Total well depth below lewd surface: 12 (11t.) 24a. For MI WCIII Submit this from within Vi class of completion of well
Far mwhlplr ants hat all depths if dini'rrmt frrmapfe-30200'and 24t,tor) constniction to the following-
10.Static water lead below top of casing: (n.) Division of Water Resources,information Processing t nit.
tr..;ar,h•.r)„i;h..,r n si,. ,,, _ I617 Mail Service Ccatcr,Raleigh,N('2 7699-1617
I I.Borehole diameter 2.25" (w.) 24h, For injection Wells ONLY: In addition to sending the form to the address in
.�4a anuse. also submit a cops of this font' within 30 days of completion of well
12.Well 4mnsaruetion method:DRIVEN constriction to the fo11uy5mg.
tic.auger.roan.cable.direct push d c.►
Division of Water Resources.Inderkrnund lstjection('untn'l Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Seri ice Center.Raleigh.\( 2'6.19-tr136
13a Yield I�Pnm l Method of test 24e.For Water S.ppls &Injrctufn Wells:
Also submit one copy of this form within elm daisof completion of
13b.Dixinfntion I)lie: Amount: well constmction to the comp, health clefs-moon of the countsAA here
constricted
Form GW-1 Nonh Carolina Lsmonnriti of Fits crone.!and Natural Rcsaurecs-Dn woo of Wales Rootnm x.,ts.d August�,I;