GW1--05839_Well Construction - GW1_20241001

WELL CONSTRUCTION RECORD For tunnel Use ONLY
The form can be used for singk or Inuit ipk IseRs
1.Well Contractor Information:
ATER ZONES
Brian Ewing PROM I to I DP'. •RIPl ION ---
Weil Contractor Nagle h. ft,
ft. I+ n,
4240-B
NC Well Contractor Certification Number U.OUTER CASING dor muli-eawd eel OR LINER of atlpkcablet
MOM i TO nrsNrTFR THIutorss MSttatsl.
SAEDACCO ft. 1 n. is.
Comp am Name WINNER CASING OR TURING weathers du+.! ed-Iu.Ip)
PROM TO DIAMETER TinUk'FSS N(itRi\i
2,Well Constriction Permit M: 0 ft. 15 ft. 1 w. SCH-40 PVC
lea all appli.wbk writ prnnin(i.e.County.Shur.Variain-e.LTP.ct[bl.-t,., ft.
3.Well Cie(chock well user: 17.SCREEN
Water Supply Well: FROM TO MAMMON SLOT SIZE ThICKNRss ; MAtURIAl.
LlAgncultural OMenicipalFubhc 15 R. 25 R. 1 Ow 010 SCH-40 PVC
DGeothemial(Heating,ICooling Supple) DResidetuial Water Supply(single) IL ft. Ie'
0Industriat'Comn(ercial DResidetltial Water Supply isMred► MIL ttRDM TO MAT8RIA1. EMPLACEMENT M111100&AMOUNT
❑bnpatian re. h.
Non-Water Supple Well:
R. ft.
IDMoneonng ❑Recovery
Injection Well: fL h.
❑Aquifer Recharge ❑Groundwater Re mediation It BAND/GRAVEL Mail analleablel
noiEl Aquifer Storage and Recovery ❑SsTllrtlt{'Barrier 13
TO MAntft4I. F.SIMACTMINT MEMO
13 ft. 25 h. FILTER SAND i 2
❑Aquifer Test ❑Stommatcr Drtinigc ft. h.
❑Eigsennicntal Technology. ❑Sabsidcrcc Control _
U.DRILLING LOG(attack additional sheets if nenwars t
OGeothennal(Closed Loop, ❑Tracer ntom TO Di.CRRtIO' .oho,sosisr.......c.wL I.Po.p,.rw vre.tit.1
OGeothennal(Heating.+C'ooline Rennin DO her Iexplain under 02 I Remarks) 0 R 5 h. FILL SILT AND SAND
5 ft. 15 f, SILT CLAY MOIST
4.Date Well(el Completed: 99=4-24 Well 1Di►TMW-2
15 R. 25 R. SILT CLAY MOIST TO WET
5a.Well Location: ft. R. — i - - -'-. j:.
Fuquay-Varina Elementary School It. n,
Facolin Conner Name Facile.IDill(ifappbeabk( ,� h OCT ! 1'124
6600 Johnson Pond Rd., Fuquay-Varina, NC, 27526
IL El.
Pbn steal addiesi Cm_and Zip 2L RZMARKS V .A, -"'-'
Wake Temporary well for grab groundwater sample -cl '$
('nine, Pared!demsfseAuna N.. 1 Pl\I
Sb.Latitude and I.ringituuk in degrees/minutes/seconds or decimal dei recx: 22.Certification:
if well lkld ow latIoiu I..Wfki mV
N W Brian Ewing 9/12/2024
Signature el-Certified Well Contractor Dote
6.Is taro)the welltzi: : Permanent or 3DTemptiran 16 agnate this form i kerrby rerrifr that the we41f, Ins fiirnrl cortrflnrred to muin once
with I S,1 NCAC O;C 0/00 or I SA NC4C 02(.0200 Will Constrwrtion Standards and rhar a
7.Is this a repair to an existing well: l'esi or ENo i.np,Of rat,re:on/ha.!Mori provided to doe urn.owner
if this is it ropier,ill owl trirne urq.[Nair1n rani twforwsan.a1 awil e.uhuos rw.•n rare of Mr
repair ander III rr,.iaria section or an the bail of this fors... 23.Site diagram or additional well details:
You may use the back of this page to pros ide additional well site details or well
S.Neither of wells roRatrimted: 1 construction details. You may also attach additional pages if n essatt.
Ft.roahrpl..injection or Non-kart swats wells ONLY with nor same rwastrwrraw ..•a.ton
suhour.•n.en,, SIIBMiTTAL INSTUCTIONS
9.Total well depth below land surface: 25 (FL) 24a. For All Wells: Submit this form ssllhm 10 dacs of completion of nett
For mat iplr lions list all drprhs tf atpi.feut h.0e19ide-0200',,,..1'w iota canstniction to the follnui tie
IU.Static water level below top of easing: (ft,) On islon of Water Resources,Information Processing t.nit.
It note,1.rl,..,M•.r,asuip „•,• - - 1617 Mail Service('enter,Raleigh,NC 27699-1617
11.Borehole diameter:2.25" _(in.) 24b.For Inkctlos Welly ONLY: In addition to sending the form to the address in
24aabove. also submit a copy of this roan within zo days of completion of well
12.Well coustrfiction method: DRIVEN constriction to the following.
lie.auger.rotas.cable.direct push.etc i
Dh•lsku of Water Resources.Underground IRjedleu Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699.1636
13a 1"idd IRIrRi) xlethnd of test:
24e.For Water Stilton 4'.Injection Wells:
Also submit one cops of this form within 'iu dos s of completion of
13b.Disinfection type: 4mounc well constnicnon to the count health deportment of the counts u9icre
constructed
Fenn GW-1 Minh Carolina L.yunnrnt of tun Instonetti and Natural Resources-Dieaton of Water Rsmotrces R..%sid-sirg(nt ill l