GW1--03742_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD \ For eniiiu ONLY:
ThPinform can be egad for singk orin.dtipk,tells \"�,
ln
I.Well Contractor Information:
v�V
isWAtERLONZIL
Brian Ewing FIIOM ! to DESCRIPTION
Nc11('olaractnr Name II. ft.
4240-13 rt. i h.
NC Well Contractor Cenilicalion Number 15.OUTER CASING(for uteNi-cased web)OR LINER(R a�itaUe)
►Rom To DIAMETER 111t('KNES5 MATERIAL
SAEDACCO rt• h. is.
Compwh Name It INNER CASING 02TURING(giewhertaal dase4-kt a)
FROM TO DIAMETER THICKNESS MATERIAL
2.Weft Conotruction permit th 1110100715 ft, ft. in..
list all applicable aril perurits(ir.County.Sane.Variance.Inleebat Err.! -- --
R. ft. to.
3.Well 1-sc mcheek well user: 11 SCREEN --
Willer Niiiiiii LSrll: IROM TO DIAMETER MOT sin THICKNESS MATRIUAt.
R. rt. in
O Agra uhond DMunicipal/Public
OGeothennal(Heating.cooling Snppty) OResidential Water Skylab'(single) R. rt i.�
OledustriatiContmercial DResidentwl WaterSupph (shared) M)IW1TF
IlDII TO MATERIAL EMPLACEMENT METHOD i AMOUNT
❑Imo:own R. ft.
Non-Water Sapid)Well:
R. R.
❑Monitonnt ORecosety
Injection Well: ft. n.
El Aquifer Rcchtrge f]Groutdwater Rentcdi:uion If.SANIP AVRLPACKtif applicable)
❑Aquifer Stoagc and Recosen' ❑Salinit).•Harrier ItWM TO )IirFRlrl F')IPI.HFHF\TNFTrN)D
R. ft. �
DAquifcr Test ❑SIornsatcr Drainage
R. R.
❑E penntemal Tcehnologs ❑Subsidence Control
2A DRILLING LOG tallneb additional sines if seaman)
OGeothennaltClusedLuopl ❑Tracer FROM TO DESCRIPTION t(.t.r,r,nanc..•wit nick n pt.Vv.,a ek.)
❑Geotltent al fileaatre'C'o ling Retumt 1100ther tesplain under if21 Retnalks) h. R.
ft. R.
4.Date Wells)Completed: 4-16-24 Well ID11IP-A-2-26 (EVENS) —_,--_...- Y
;a Well Location: II L-• .
Rays Grocery R. R. -- � 2024
hairy.O e nor Name Faellnt ink ifappticabkt R. ft.R.
1674 E. Main St., Sylva, NC, 28779 R. it. Unit
Pin seal Address.fin.and Zip — -
21.R[1NAlKS
Jackson DPT INSITU INJECTION; INTERVALS 6-12'
Coutah Prrcct IdciiI,l.c lt.n.l No !PIN,
5h.Latitude and Longitude in drsrnes/minuteslsccnnds or decimal demos: 22.Certification
•:d...I li.)d n.<latlrou r.,.dlicrknu
W Brian Ewing 5/8/2029
Signature of Certified Well Contractor 1,.::;
6.Is tare)the sell(sl: 'Permanent or XITemporarp
M signing Otis form 1 hrrrby certify that the*wart war(weir)coarnmeted in a eordancr
with 154 NCAC 02C.010t)or 154 NCAC 02C.0200 Well Conroe:ion Skrndords anal char a
7.Is this a repair to an existing well: IYes er E.\o rugs ofthec record has berm provided to the well Metter.
litho n a,rprur.till,art i;n„aa a c s....nano.coon.afo. iarion oral.•s'Lon d.r,artnrr or Mr
repair wader P21 remark.)A.,lion or on the hart of this form. 23.Site diagram or additional well details:
You etas use the beck of this page to pros ide additional well site details or nett
S.Number of sells constructed: 13 corrstmcuun details. You min also attach additional pages if tnx ess rat
For nwMpk infection Of Non-..ore...ytph wells ONLY nun the fame e,msrtrrtwut v:n on
salmrir same form. S.L IJMITTAL INSTUCTIONS
9.Total Weil depth bebn land surface 12 tft.t 21a. For All Wells: Submit this form within M0 dins of completion of well
For multiply arils tutall.kprhr rjdellef nrfr.rorgite-30:()0'and 2@loiTt constok lion to the following:
III.Static water lose)!rhos top of casing: (DJ Division of Water Resources,Information Processing I nit.
. . ,• . _ ,.. . 1617 Mad Service('enter,Raleigh,NC 27699-1617
I I.13..rchok diameter:2.25" tin) 24b.For Injection Wells ONLY: In addition to sending the fort to the address in
—taabose. also submit a tap) of this form within 30 dass of completion of well
12.Well construction method: DRIVEN constni tiontothe followalg
li e.auger.rain.cable.direct push etc I
Des ision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mad Service Center.Raleigh.NC 27694-1636
I3a.Yield(LTmt
Aletbnd of test: 24c.For Water Suppis &Injection Welts:
Also submit one Bops of this form nithrn t0 da_ssof completion of
t3l.Disinfection hpe: Amount well conatnrctlon to the count) hcahh department of the count)where
crnKtntcled.
Form GW-1 North Carolina Deporunait of Eat umtorin and Natural Resources-Dn Woo of Wale!Resotrcm Re.used August Ili I I