GW1--03881_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD ForltacrnnlUscONLY
This loin.:,;v h•need for chi,.Ic or multiple wells
1.Well Contractor Information:
11.WA1RR ZONN$
Brian Ewing FROM TO DRS('RIPTU)N
N'c11 C'nrsncH•r Name
n. ft.
ft, ft.
4240-B
NC Well Contractor(efifaalton Number IS.OUTER CASING(for tte.Ni eased wcUs1 OR LINER of able)
FROM TO DRMFTFR THI('A\TSS JIJ NATTRtia
SAEDACCO ft. 1 n. a...
('nmp;un Nam.: 16.INNER CASING OR TURING(jsntbermal closed-loop) -
FROM TO DIAMETER Tilt A\ESS NA TTRI.AL
2.Well Construction Permit 4: 0 R. 2 ft. 2 ila. SCH-40 PVC
List all applicable well permits(Le.Cotrnte State.Variant, Itgerr)arl nr.1 ..
ff. R. ha,
3.Well Uae(chek well use) 1t SCRUM -
Water Supple Well: FROM TO DUANF1TR s1.OTsinn ! IMt-104% N',Tr.RtAt.
UAgncultural OMunicipaLPublie 2 ft. 7 ft 2 in, 010 SCH-40 PVC
fiGeothetmal(Heating/Cooling Supply) °Residential Water Supply(single)
ft. ft. in.
CllndustrialiCommercial °Residential Water Supply(shared) 1&GROUT
FROM TO MATERtst. EstrLs(fME\T ME 1110D A AMOt]T
❑lingatwn ft. ft.
Non-Water Supply Well:
ft. ft.
®hlonitonni; ❑Rocovcry
Injection Well: n. R.
❑Aquifer Recharge ❑Cimundnater Rcrnediation 1f,5ANINGRAVRLPA7Of ap}Nea Ie)
Aquifer Storage and Recover ❑Salinity Barrier FROM TO MATBRLU. r.MPI.4(FNI'VT NFTHOtt
❑
1 ft. 7 ft. 1 FILTER SAND # 2
❑ rl Aquifer Test ❑Slomsatcr Drainage JI
ft. ft.
❑Experimental Technology ❑Subsidakc Control
111.DRILUNG LOG(ailseb additional sheets if iscetssar J
❑Geotllennal(Closed Loop1 ❑Tracer FROM I TO DWSCRt/TtON Rater,harder..,..it'nwi n pr.grow wa•,us
❑Geotlienrlal(Heating/Cooling Return) ❑Other(explain under M rnaiL?I Res) 0 R. 5 fL FILL SILT AND SAND
5 ft. 7 ft. WET SANDY SILT
4.Date Well(a)Completed: 5-9-24 Well!DO TMW-7
ft. ft. • _
5a.Well Location: ft. ft. F``L E;V E D
Gaston Refuse Disposal ft. f1. JUN 8 2024
Fat ilso(i. •'a i r, Faclim 1DoT(if atpplicabkl ft. tl.
250 Porch Dr. , Gaston, NC, 27832 ft. i ft. l a'��ycq'�r'jum
Ifriv:7.'dert C'
Plnsical Adfress.Cin.and Zip 21.REMARKS
Northampton BENTONITE SEAL 0-1'
('am r. Parcel IdemifiesUoa No IPINt
Sh.Latitude and Longitude in degncalminutesisccnnds or decimal degrees: 22.Certification:
of well fold.Isle Latlang IS stdlicwm(
N W Brian Ewing 5/17/2024
Signature of Certified Well Comi J.1 Dale
6.Is lare)the wellltit: :7Permanent ur IflTemporary By signing this farm 1 hereby terrify that the well(a4 eggs(wwri tansmwied in accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 022C.0200 Well Construction Saaata,.6 and that a
7.Is this a repair to an esisting well: JYes or RI Nn cops of this word has seen pmridrd to the well owner
If this n a repair.fill oat knout.'urn,<$utnw HMI utfonwtkm and r cplo,i rh.e,rwr(.4 the
repair coder 921 rernants section or rat the hail of this form. 23.Site diagram or additional well details:
You may use the back of this page to pros ide additional well site details or well
8.Neither of wells coestracted: 1 constmetion details. You,nay also attach additional pages if necessary.
For nruh(pk injection or non-water straps wefts ONLY,trh rim sane construction te.0,e.o
submit one faun. SUBMITTAI,INSTUCTIONS
9.Total well depth below lied sorface 7 (R.) 2.1a. For All Welk: Submit this form within all days of completion of well
For instep!..wills list all depths if duff rent lr.T mpte-.1*200'and 2*l00'I constriction to the following-
IU.Static water Mel below top of easier (MI Derision of Water Resources,Information Processing I.nit,
If water level n(Awe rasing.ore"a" 1617 Mail Service('cuter,Raleigh.NC 27699-1617
II.Borehole diameter.4" (fa.l tab.for!election Wells ONLY: In addition to sending the form to the address in
24a abos e. also submit a copy of this form within 30 days of completion of well
12.Well coestrletion method: RAND AUGER construction to the follow wg-
li e.auger.ratan.cahlc.direct push.etc.1
Division of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Set.ice(enter.Raleigh.NC 27699-1636
lie.For Water Suppls A'.Injection Wells:
13a.Yield(gpm) Mrfnid of test:
- Also submit one copy of this form within u) day s of completion of
1311.Disinfection type: Amount: well construction to the county health department of the county where
constructed
1•.oiti t:w-! Noah Carolina Lkp rnnictu of Em tiotlltitu and Natural Resources-Di'w400 of Water Roovea Re.tied August H113