GW1--03738_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD Fur Imcn ItheONLY
The form can be used for singe or oniltiplc wells
I.Well('untractur Information:
14.WATER ZONES •
Brian Ewing FROM to DvsceirinlN _
W411 Contractor Nan: ft. ft
ft. ft, ,
4240-B
NC Well Connector Certification Number IS.OUTER CASING(for sRthiraxdl nclht OR LINER of ep lea k)
FROM TO DIAMtTFR THICKNrsS MSTTNI%1
SAEDACCO f. n. is.
Cmnp ue Nave If.INNER CASING OR 11L'RING usher>rd cIsI estop!
FROM TO DHNFTER TOMANE'S Ms1IRUI
2.Wes C..Ftntcti,.Pen.it to NI0100715 O. pi. ,
List all applicable well permits(Le.County.Stow.Variance.!steam ehr..r -
ft. It, in.
3.Well lie ached:ern owl: 17.11012E4
WaterNnpph Wclla PROW TO DIAMPTTO .Luc o Hill
rs nmW ., AiSIIRIAL
I IAgit.uluu;tt OTatunicipal/Public R E is.
C)Geathennal(Heating,Cooling Sutply► ❑Residential Wafer Suppl (single) R rt. to
LlludustriaUCommcrcial OResidentwl Water Supph(shared) ILGillm OT
ROM TO MATERIAL EMPLACEMENT ME TROD A AMOUNT
❑lrrivatinn h. ft.
Non-Water Sup(t1'Wen: '
ft. ft.
ElMontton op ❑Rec(wcn'
Injection Well: R ft.
❑Aquifer Recharge ❑GroundwalcrRcmedi:Ilion It$ANIIMP.AVRL.PACK(1,loalleaMt)
❑Aquifer Storage and Recover ❑Salinil< Earner F�M TO MAMMAL rNn.Ad TAUNT METHOD
R. ft.
❑Aquifer Test ❑Stormssatcr Drainage
ft. ft.
❑E:cpcnmcntal Tahnnlo}•A ❑tirrhsidersce C'otrlrol 20.DRILLING LOG firma additional sills if secow'.I
OGeoihcnnal(Closed Loop ❑Tracer FROM To DESCRIPTION•mine.tawuus.,...rout.I.tr.es....r<-.di 1
OGeothcnnal iNeaung:Coolinlg Return) DOOtlier(explain under#21 Remarks) nr ft
ft. l ft.
4.Date Wells)Completed: 4-21-24 well m.IP-C-2-26 (EVENS) h !
SIP Well Location: ft. ft. . ,....`•, . •• V
ELi
Rays Grocery ft. h. JUN 9 1 2024
Facility TN ser Name Facdin MN Of applicable)
ft.
1674 E. Main St., Sylva, NC, 28779 ft Ifrfv 7 +it 1
t.
Plnsical Address.Cit..and Zip Qhi's 1,-`+
2L REMARKS
Jackson DPT INSITU INJECTION; INTERVALS 6-12'
t'nwn Parcel ldesuf aUon No (Mt
Sb.LaNhfde and Leasiulde I.degrealmiltelteslsccnnds nr decimal degrees: 22.Certification:
Orwell field.uste latilona(s s ciest)
N W B •
rian Ewing 5/8/2024
Strohm ofCertified Well Cann,.1 Ira:;
6.Is(are)the wdks): ❑Perrwanent or RITemporat'y
Ut Wining Ilea form.1 berebr•certify that the welllsl was(lanai omrbw•red in acronke nr
with I SA NCAC OX.010)or 1 SA NCAC M.0.0200 Weil Construction Standards and the:a
7.Is this a repair to an existing well: -.1 es or IC No ropy of Air reamed has been pmrwlyd to the iwO owner.
If•his It r7 relwter,(ill loll(pawn writ.tau:•..hoe,7nlbmh,r;on aanl rt116o1 U•r n.:r:o t of ate
repair ender 1,21 reenter*v section or on the hark of this form. 23.Site diagram or additional well detail!:
You mas use the bacl,of hits page:to proside addiliotral well site details or well
8.Number of wells coisslt'.n:ted: 13 construction details. You mos also attach additional pages if Iks.esSan.
For mwluple otfeer/an err oral-inter uq+pls welts 011iLt..:rh rho same<r.gstrwrrion vr.w<(an
safmnit.om•form. SIIBMITTAL INSTUCTIONS
9.Total well depth below land surface: 12 (ft,) 21a. For AR Wells: Submit this form whim 10 days of completion of sell
For ntatople wells tall all rkpths 41 dttterenr texample-4,'ZOO'and 2@ 10'Yt eonstnretion to the following;
It.Stalk water Wirt below top of casing (ff.) Division of Water Rals.reei,Information Processing I nit.
If wirer kvr!es uh...r,.,r,e,; - 1617 Mail Service Ceaer•,Raleigh.N('2 7699-1 6 1 7
I I.Borehole diameter:2.25" (in) 2-lb.For Icksilea WO ONLY: In addition to sending the form to the address in
2-la abose. also submit a cops of this form within 30 doss of completion of well
12.Well co.str.etion method: DRIVEN col is(ruction to the following.
tic.auger.ratan.cable.direct push.etc 1
Ohkiun of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1634.Mail Serice Center.Raleigh,N( 2'694-1636
tie.For Water Suppl. S.Injeetiirn Wells:
I3a.)Vivid rgpm I __ Method of test:
Also submit one Cops of this lame ssithm ;0 doss of completion of
lib.Disinfection tspe: Amount: well construction to the corms health department of the count where
constructed
Form GW-1 lonb Carohna Depannwiu of Ent titanium and Natural Resources- D s sloe of N ant Reotrces Re.met'August 20I r