GW1--05798_Well Construction - GW1_20240926

WELL CONSTRUCTION RECORD For!mental Use ONLY:
Thu fnm can h:ns.d for si i k Of moll irk hells
1.Well Contractor Information:
M.WATTE ZONG4
Brian Ewing non To Dt:4('IttPI ItIN
Well Conn:loot Nana n. ft. __-_-- -
4240-B h. ft,
NC Welt Cornnxtor fen mat on NambeT 15.OUTER CASING(far s uki'casrd orbs)OR LINER IS applicable)
FROM TO DInMTTfR TN rsotrx5 MATTIIRI
gaar&CCO h. h. h.
('ompaa)Nana MANNER CASING OR TUBING(1.s hers,a Mal-hog
FROM TO DIAMETER TRK'K%Rss MATERIAL
2.Well Construction Permit N: 11I0300529 ft, ft. Ia.
tarp all applicable well penult,lice.County.State,Variawre.itOtirliatetc.I -- •,.
3.Well Use(check well use): 17.SCRUB
Water Supply Well: FROM TO DIAMRT►R MAT31r) THICKNIFIS MAtflhil.
DAgrlcultural DMumelpat/Plublic ft. ft. ra
OGeothetmal(Healing/Cooling Supply) DResidcnnal Water Supply(single) h' ft. to.
Ohduslrial/Comntercial DResidenitwl Water Supply(shied) IS GROUT —�
FROM TO MATERIAL. t tlt•I tI I tic's I %It MOO A.A(ovNT
Ohngalron ft. ff.
Non-Water Supply Well:
-
ft. ft.
❑Monitonne ORecoyeny
Injection Will: II. II.
0Agnifcr Recharge FCironndwatcr Remedial ion 1s...y\6(.R sv iI F u h ut aatlwable1
OAquifcr Storage and ReCOVel' OSalinih Hamer ►Rost nlatFRIyl. FMn.ArrervTM.
h, ft.
O Aquifer Test OStomnsatcrDrainage -�i t ft.
❑EWcnmcntal Tcchnolo4s OSubsidcncc Comm!
20.DRILLING LOG(allseh...l,l i l n n.a i.1. 1.ii toped))
OCieothcntral(Closed Loupe OTracet FROM To DIM RtplIt IN.0.1.r. wlKath„_ se.
OGcothc teal IHeatnrg.'Cooling Return NOther(explain under 021 Remarks, n• 84
ft. 11. 1 .`:"..A..•'a... .V 1._f )
4.Date Well(ntCompleted: 8-30-24 N ell IDaA-2-14(EVENS) SE /f
Sa Well Location: It ft SEP 2 u 2024
Downtown 66 ft. R. IaS74J' .e. rr•,^3a43-:1I.ji:tl
Factlns,CIu nor Nana Fxilre IDM(if a,plicabk) ft. IL Qt,Ill!ei.32
232 E. Marion St., Shelby, NC, 28150 R. ft
Pineal Address.Cis.and Zip 1 21.RCMARKS
Cleveland PUSHED DPT TOOLING FOR INSITU INJECTION
(.,,ni.r. Fend 4k,n decal n',No. I FIN t
Sb.I,atiWdc and I.ongitutk•in(k7(lrenimina ten/woods or decimal degrees: 22.certification:
III well field ma la..long is stdl'aaulI
N W Brian Ewing 9,12,2024
Sigmt to of(certified Well Contractor Dote
6.Is(are)the%rills): 11Permanent or ETemporary
By signing Ow form.l herd,'cefgry awl the well,,win(sorrel,rowsnurred or arordtnur
with I�S(A NCAC 02C.0100 or a SA NCAC 02C.0200 Well Construction Standard,and that a
`J 7.Ls this a repair to an existing well: Y es or E No o .'
raps r•hit record ha,been provided In OW Wen owner.
If this it a repair,(ll4Mr 4n1,101 wells mutt*lion,nformutwm ma!r%plain rh.•misrule of rho
repair wider 121 rnawrks,rotten or iv.the back of this fors.. 23.Site diagram or additional well details:
You may use the back of this page 1.)prosrde.ddttionad well site details Or ncll
S.Number of well constructed: 7 construction details. You may also attach additional pages II necessary
for maltple rnjerrh,n or min-water tupplt wells ONLY with rhw Maw constrarNoe.we can
.submamale Prot. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20.25 pry,) 24a. For All Wells: Submit this form w'thin 30 days of completion of well
For multiple welt.lit,a0 depths ride!;, ,,',esmnpfe•3e200.and 201001 constn•ction to the following
10.Static water yewel below lop of casing: (n,) Division of Water Resources.Information Processie*Unit,
1/Moire lore it.tb.n'r.n,v.z I,.-I' . 1617 Mail Service('enter,Raleigh,NC 27699-1617
II.Borehole diameter 2.25" (in.l 24b.for iniection Wetly ONLY: hi addition to sending the form to the address in
24aabase. also submit a copy of this form within 3(1 days of completion of well
12.Well construction method:DRIVEN construction to the following.
lie.rigor.rowan.cable.direct push.de.)
Ohisian of Water Resources,Underground Injection Control Program,
FOR W'.ATER SUPPLY WELLS ONLY: 1636 Mail Sees ice Center.Raleigh.NC 27699-1636
Lla i tell(t Prot Method of tent: 24e.For Water Semi,. &Injection N'elln:
Also submit one cony of this fumy within to dots of completion of
IJb.Disinfection type: __, Amount: well construction to the county health department of the county where
constructed
Form GW-t North Carohwa Lhpunu/enr of Em imimnw and Natural Resources-Dineen of W airs Rmoircm Rev wed Moat 2013