GW1--03876_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD Pot!Menial lise ONLY:
This form can M used for sinek or mull MSc tells
1.Well Contractor Information:
14.WAT[R ZONIS '
Brian Ewing ►ROM TO Drti(•RIPT10V
%Veil('minio'r Rank ft. ft.
rt. n.
4240-B
NC Well CoraractorCenification Number IS.OUTER CASING Ow multi-easel sigh)OR LINER tit al�litable)
FROM TO DIA\IrTFR THICIOsi.S I MATT RI\(
SAEDACCO n. n. i..
Campus?Name 16.INNER CASING OR TUBING ijksistlielyisal ehaed-ho9j _ `— .
FROM TO DIAMETER Tilt(•KNESS MATERIAL. _
2.Well Construction Permit If: 0 ft. 5 ft. 2 iii. SCH-40 PVC
lie ull upplwab a writ permits(tr.Counts..Stmr.Variarrr.bixoo2 es.., - -
fl. R.. in.
3.Well CTe(check well awe): 17 M -
Water Supply Well: mom TO DIAMETER s1.0''.'7r Intl WO,. NI%I F RI U
OAgnculttural OMunicipaliPublic 5 ft. 15 ft. 2 is .010 SCH-40 PVC
OGeothemial illeatingCooling Supply) ❑Residential Water Suppl (single) R' h in.
i
OlndustriaUCommercial OResidential Water Supph IsIvired) I&4 0IIT
PROM TO MATERIAL EMPLACEMENT METHOD t AMOt T
❑Irrigation ft. ft,
Non-Water Supply.Well:
ft. ft.
NMonitonng ❑kccovets ,
Injection Well: n•
°Aquifer Recharge ❑Groundnater Remcdiation 19.SAND(GRAVRLPACIrlif applkahk)
most ' to 1 M%TrRIiI. EMPIA(F\IINT MFTHOD
❑Aquifer Storage and Recovery. ❑Salinity Barrier 3 ft. 15 ft. FILTER SAND # 2
❑Aquifer Test ❑Slormwater Drainage
n. ft.
❑E?cpenmcntal Technology ❑Si4 sidcrwe Control
NI.DRiLUNG LOG(attach additional sheets if demurs
OGeothennel(Closed Loops ❑Tracer non To Dt?s('RIPT10's osier,lards...warns I opt.vain ire.rk-I
OGemhennal IHeatiii Cooling,Return) ❑O her(explain under M2I Remarks) 0 h. 5 II. FILL SILT AND SAND
5 ft. 15 ft. MOIST TO WET SILT/ CLAY
4.Date Well(s1 Completed: 5-7-24 Well IDS TMW-6 ft, ft. r " -4 i- . ;
Sa.Well Location: ft. ft. C(. JED
Gaston Refuse Disposal IL f. JUN 9 8 2024
Fa:dm.0a nee Name Factltn IN(if applicable) A.
250 Porch Dr. , Gaston, NC, 27832 n n ir..MA uI(\l:'--. ,a;,.T'JO
Physical Address_('its_;Ind 7ip Drl.C$304"
21.RCMAan
Northampton BENTONITE SEAL 1 TO 3'
('oaoh I'.uu1 Ideaifrtation No ,PIN m
4h.Latitude and I.nngitu(Ie in tiegas-sort linutrs.sccnnds or decimal degrees: 22.certification:
pl e.l:Is J one tat long,.hid nc i.ui1
N W Brian Ewing 5/17/2024
Simone of Certified Well Cow,,.i Date
6.Is 1 arc)the well(a) OPerRsannent or 1tiTemitorarp By signing tfu form 1 hereby(unify Mrs the NIH(5I ray(arm)enarr►acted in axnrdmrrr
with 15A NCAC O2C.0100 or 15A NCAC 02C.0200 Well Conanrirrlo t SAaadards and that a
7.b this a repair to an exislie well: ❑Yn or Elkin copy of this record hos brew provided to the well owner.
if th,s It i I 41,410.fill UUt tnl,µq Well(MAAAR lust nr.6,o areal Bull a Sphi.,the Iµtrare of Ow
repair ruder on remarks srrliaa or on the bait:of this form. 23.Site diagram or additional well details:
You oral use the buck of this page to pros ide additional well site details or well
8.Number of wells constructed:��fs1l constmadditionalg ction details. You may also attach pages if necessary.
For rwwldplr ntiferwsm ohm•µ ter aspp went ONLY own Ole Malt construction von<ory
sabmir<,vw form SUBMITTAL INSTUCTIONS
9.Total Orli depth belun land surface 15 (ft) 24a. For Al Welk: Submit this form ssilhrn 30 days of completion of well
hoe malrgrk wells hot on tkptlis ifdifferent fexawapfe-30200.and 2 R 100) constmction to the following•
le.Static water level below dap of casing (n,) Division of Water Resources,Information Processing Unit.
It Hake lr,r1..idr.,,r,„,,;.: . 1617 Mail Service Center,Raleigh,N('2 7699-16 17
II.Borehole diameter.8-25" eta) 24b.For lnjisrlion Wells ONLY: In addition to sending the form to the address in
24aabose. also submit a copy of this form within :o days of completion of well
12.Well construction method' BORED construction to the follow Mg.
lie.auger.roan,cable.direct push etc.)
Division of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 2769.9-1636
l3a Yield 1>;Pm1 �Irdu,d of tr.r. 24c.For Water Supph A,Injection Wens:—— Also submit one copy of this futin within tut days of completion of
1.111.Irisinfectinn q pr: Amount: well construction to the county health department of the counts where
constructed
Form GW-1 North Carolina Department of Em Iioluneni and Nursed Resources-Division of Water Resources Res ised August 1)11