GW1--03880_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD For incrnal Use ONLY:
This form can be used(.mot single fir molt ink wells I
1.Well Contractor Information:
II.WATIR ZONE
Brian Ewing FHOH I Io , DP.M RtP11Or
Well Contractor Nance ft, i ft.
4240-B ft, f ft.
NC Well Connector Certification Number 15.OUTER CASING(for multi-caned wcisi OR LIN ER Iif able
IRON '. TO j DI\MFTFR THICKNESS MATT Nisi
SAEDACCO h. h. I..
(•atlyl;ul) NJtnl le.INNER(•ASINGOR TIBING�tharmalcluscd-laopt _
FROM —
I TO .-- DIAMETER T1II(Is\ESS MATTRUI -�
2.Well('onstruetinn Permit 0: 0 ft. I 10 R. 2 IL SCH-40 PVC
Lsr all applicable well penults(i-e.County.Stair.Variance.(beerier rin t ft. i 1 It hi.
3.Well 1-µ icheci:\tiell use); 17.SCREEN
Water supply 5.sdI PROM TO DI.\tFTI It— .If)1\In� rnl(WO..., MATRRIAI.
1_IAgrkultural OMtmicipaliPublic 10 ft. 20 ft. 2 Iw .010 ,SCH-40 PVC
COGeothemial(Heating/Cooling Supply) OResidential Water Supply(single) R. ft. In
fllndustriaUCommencial DResidential Water Supplyiskired► le'®OUT
iROM TO MATERIAL. EMPLAC EMEST NIL TROD AL.\\WI\T
❑Irrigation ft. ft,
Non-Water Supply Well: I
ft. ft.
®Monitorin►; ❑Rcco\cr __
injection Well: h- h•
Cl Aquifer Recharge OGroundwaterRcmcdiation i $AND/GRAVRLPACK11Isinlimh4) -�
f.
PROM TO MAT/NMI. ESIP1.t(t%1F\T MrTHOO
OAquifer Storage and Rccotrty ❑Salinit} Harrier 8 R. 20 ft. FILTER SAND # 2
13Aquifer Test ❑Storrmsatcr Drainage ft. ft.
❑Experirnenaal Technology ❑Subsidence Control
25.DRILIJNG LOG(attack addidaaal sheets if areeassn)
❑Geothermal(Closed Loupi ❑Tracer raosi TO orscniPT1O5 Iral.r,II■wn.•..,...a.nwk I,pr.train be.ce i
❑Geotheal(Heating/Cooling Return) ❑Other(explain under#21 Retnilks) 0 ft. 5 ft. FILL SILT AND SAND
rm
5 R. 15 ft. SILT CLAY MOIST
4.Date Well(s)Completed: 5-8-24 well mgTMW-1 15 R 20 tn. SILT CLAY MOIST TO WET
5a.Well Location: h. R. �' y ti�J
Gaston Refuse Disposal ft. ft, ``'
Fail lib.011MrNjII''r Facility(ON(if applicable) ft. ft. JUN 8 )O),f
250 Porch Dr. , Gaston, NC, 27632 h. ` LY
Irrfv:'kc
Plnsical Address cis.and Zip f.l�'�^ ;_-� 'Jail21.REMARKS [Aj i i 2(
14
Northampton BENTONITE SEAL 6 TO 8'
('nano i'enclldcntdre::nionNo I PIN I
5h.Latitude and!.nngitark in degtees/minutes:Seconds or decimal degrees: 22.Certification:
(d oil:Iwld nis tab lase Is\Idlickvi1
N W Brian Ewing 5/17/2024
Sig a ofCcnillled WcIl cow,,.1. fray
6.Is(are)the well(a): DPermanent ur NT'emporan g\. ,,,,, tier f kernbi re
�a X am. rtif•!'401 flee iietits1 rev(real crmsm reed in arronlmnr
ride 15.4 NCAC 02C.0100 or I SA NCAC 02C.0200 Will Conanrerdon Standards and rkar a
7.Is this a repair to an existing well: J Yes or E No rapt nfthir record has farm pm idrd to At rrlt earner.
l//bps I..a twine tin on it known net!.twain,now nrjornaill.,ata1.•retool the nature of the
repair amlrr I'l rrn,ant.,.section or on the back of Mir form. 23.Site diagram or additional well details:
You tiun use the back of this page to pro\rdc additional well site details or sell
8.Number of wens COntstrueted: 1 construction details. You may also attach additional pages if necessary.
For sample inje rkan of wart-wares wools seeH&ONLI•with the isms coaalracdaw NMI cent
sabots one foam. SUBMITTAL INSTUCTIONS
9.Total wdl depth below land aserfacc 20 off,) 24a. For AU Wells: Stimuli This form within 30 days of completion of well
For nrairiple wells liar all depdes if different termites.-3@200'and 240 WI1I construction to the following-
10.Static water level below top of casing: (ft.) Dh'isiun of Water Resources,Information Processing l nit.
if nailer level a alarm.a!rne are '. 1617 Mail Service('cater,Raleigh.NC 27699-1617
II.nNeeYote diameter:8.25" (ia.) 24b.For inkctioa Welb ONLY: In addition to sending the form to the address in
24a abin e. also submit a corn of this form within '30 days of completion of well
12.Well construction meried:BORED constmetion to the following.
I i e.auger.rear..cable.direct push.etc.l
Dhision of Water Resources,tinderf(Iround injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 21trr9-1636
13:1.Yield limn) Method of test 24c.For Water Sepik Jr Injection Welk:Also submit one cops of this form within io dad s of completion of
I.Ih.Disinfection t\lug: >mount: well construction to the county health department of the county where
constmcicd
Form GW-1 Noah Carolina Dcpmrnieni of Ern uonruni aid Natural Resources-Do,noon of Water Rmoitto6 Res wed.August?sill