GW1--03879_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD For hared UseONLY:
This form can Ix used for single or rnulnipk wells
I.W'dl Contractor Information:
114.WATER ZONES
Brian Ewing VkO i ' io dtti('RlPilnN
Well Contractor Name ft. 1
ft.
4240-B ft. ft.
NC Well Contractor Certification Number 15,OUTER CASING(lerMRMi•eaml»c.sl OR I.INFR lit appP'reble)
ratio 7 To ' DIAMFI of THIS In\rsti S111TR1%l
SAEDACCO II. " +'
Campo')Name 16.INNER CASING OR TVUNG(Rntherstal chased-hop)
'-MOW _ TO - DIAMETER THICKNESS N.11T RUI_
2.Wdl Constrtrction Permit#: 0 ft. 15 ft. 2 tL SCH-40 PVC
List all applicable wellprnnitr tie.County,Sane,Variance,injection rtr.l --
fl. fl. is.
3.Well y
'!t(checkled vise): 17.SCRtt1V 1
Water Supply Well: IRON TO I DIlMiTTR MMOTSI7r THICK!IFSY i MATERIAL
0Agricultural OMtmicipatPublic 15 ft. 25 H. 2 IlkO10 SCH-40 PVC
°Geothermal IHeating,Cooling Supply) OResidential Water Supply(single) ft. ft. ail.
Din ustriaUComtnercial OResidentwl Water Supply(shared) 18 GR�fr
PROM TO MATERIAL 1 EMPLACEMENT METHOD&AMOUNT
❑Irrigation R- ft-
Non-Water Supply Well: ft.
R.
ICKlonitonng ❑Rccovciy ______.
Injection Well: ft. ft.
-
°Aquifer Recharge ❑(.imundwaterRcmcdiation If.SAND/GRAVEL PAOCOfaggliva le)
gAquifcr Storage and Recovery ❑tialinih Harrier 13
Ito MATRRtat. r.MP1.UCTMENT MI llinn
13 ft. 25 ft. FILTER SAND # 2
gAgiufer Test ❑S*ormatcr Drainage ft. I ft
OEapenmcntal Technology ❑Subsidcncc Control i
Bt.DRILLING LOG(attach additional shoe t i(aactaran)
OGeatlerul►I(Closed Loop) 0-Tracer /most 10 DESCRIPTION arst.r,harems.wWnek opt.Armin..i.e.,rot.' •
OGeothermal liieaulig/Codliig Return) ❑Other(explain under#21 Remarks) 0 ff. 9 tt. TILL SILT AND SAND
5 ft. 25 1t. MOIST TO WET SILT/ CLAY
4.Date Wetl(a)Completed: 5-8-24 Wd1 ID#TIM-2 ft. rt
5a.Well Location: rt. ft
Gaston Refuse Disposal R h %;,,��,L. f t L)
Facilm Ots err Nam,: Facility IDN(if applicablcl --mm i
R. R. LLLN 2 8 ZU24
250 Porch Dr. , Gaston, NC, 27832 rt. D.
Physical Addncss.City.and Zip 21.REMARKS ir'riv:T'fi.t.('rl ''''-^AnQi p UM
Northampton BENTONITE SEAL 11 TO 13' i71,'.' ,tt�v
(*comb Parcel ldtaadac:ataua No I PIN'
5h.Latitude and Longitude in degr esiminutcsisecnnds or decimal degrees: 22.Cerfif cation•
{al well field one Ian long is mink wral
N W Brian Ewing 5/17/2024
Sig of Certified Well Convector I a,t'r.
6.Is(are)the wallah ❑Permanent ur >OTemporar)
By signing this fair.!hereby certify that the welllsl argils from)evnartrmet d in accordance-
with 1 SA NCAC 02C.0f 0)or 15A NC4C 02C.0200 Well Construction Standards.ant that a
7.1s thin a repair to am existing well: 1 es or E No myna ofrhir record has herr'provided rn the wall owner.
If this is a repair,fill nut trr..wa w rt1.<N'o,u,;VW inlareSrtn,,i curl.•Vieth'',the nut ere of the
repair ceder 1121 remarks se'aiorr or as the bunt of this farm. 23.Site diagram or additional w ell details:
You Inlay use the hack of this page to pros isle additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple rafeeuo a Of naNi-wester supph wells ONLY with the warn(ono,action row sae
sahnait,ow k,rer. SUBMITTAL INSTUCfIONS
9.Total Nelt drink NAM land surface 25 (ft.l 24a. For All Wells: Submit this farm within 10 days of completion of well
for multiple wells last all depths of dtj)?rent tr.raaupfe-3e200'and 2%!01'1 construction to the following
IS.Static water lewd bd.w top of casing: (R.I Division of Water Resources,Information Processing I nit.
If wilier lrrrl n dime asiax.mu. '+ 1617 Iliad Sen-ice Crater,Raleigh,NC 2 7699-16 1 7
II.Borehole diameter:8.25" (ice.) 24b.for(niceties Wells ONLY: In addition to sending the form to the address in
24aabose. also submit a cops of this form within ?0 days of completion of well
12.Well construction method: BORED construction to the following.
I)C.auger.roan.cable.direct push.etc I
Division of Water Resources.underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: I636 Mail Set ice('enter.Raleigh.NC'2 7699-1 636
24c.For Water Supply S Injection Hells:
13a.Yield(Rpm) Method.f test:
Also subnnl one copy of this loon within to days of completion of
13h.Disinfection h Inc: mount well construction to the county health department of the county where
coastnictcd
Fonn GW-1 loth Caiolma fgiunnrui of£m uoima:au and Natural Resources Dn as ion of Walcr Rootrcm Rev wed Atgtat Rill