GW1-2022-03590_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD For Intcriol Use ONLY:
This form Qiri be used for single or rmillipk%veils
1.Well Contractor information:
I4.%ATER ZOHES' _ .
Brian Ewing FROM TO DF_S(1RIPTION
Well Contr:tctot Naox rl rl
4240-B
NC%X16l Comnaor Ccnifnalion Number 15.0UTER CASE, for'' uhi-coved tits OR LiNER(if:a lkable
FROM I I VtAMF.TFR- 1n1CKNFsS MATERIAL
SAEDACCO Inc 0 ft. 8 ft. 2" in. SCH-40 PVC
(.'mrgr:un Naurt 16`INNER CASING'ORlTUBING J totberrnat ck wd4olq
FROM TO _ D1.41tETER TIIICKNFSS MATLRIAL
2.Well Construction Permit N: tr, I (I. in.
Ira a!1 ayplirnhle a rll prnnits(ix.C.ounrc..St are,_%nrianre.I#*er6C t e/r.)
fl. fL
3.Well Use(check well usc): 17.SCREEN
Water Supply Well: FROM I TO DIANfVTVR 1.0TSl?X Tff1(1lNrS$ MATf:RIAt.
GJAgrieultural ONlunicipollniblic 8 fl• 18 tt. 2" in. O10 SCH-40 PVC
045cothemtal(TieatingtCooling Supply) DResidential Water Supph•(single) U. If• in.
h IndustriallConinicrcial DResidential Water Supph-(si ared) TR•GROUT.
FROM TO MATERIAL I EAiPI.ACF:,yLNT Mt:T110D A AMOtiNT
❑irti ation 0 h, 4 h. PORTLAND POURED
Non-Water Supply Well:
ft. fl.
Okloniloring ❑Itccovcty
injection Well:
DAquiferAcchargc DCJroundnatcrRcntcdiation <I9.SAND/GRAVELI1ACKf!fafqdkaDle
rails( 70 �tATF:RLah EMVI.Af'FYt1;�TMYfn011
❑Aquifcr Storlgc and Rccotrrr• ❑Silinity liarricr 6 fl. 1 18 ff. FILTER SAND # 2
0Aquifer Test 1I tommatcr Drainage fl ft
❑>xpctimcn(al Technology ❑Subsidcncc Control
20'DRILLING I OG.1aitsch additional sbcets if rltccsmyiT
❑f;,:ottennal(Closed Loop) 07'racer FROM To DFSCRtPnON ltdbr.Fnnlncv:,>,Iun,rk tv �a r.ac t
Ot:rrothennal(Reatine+Cooline Return) 001her(eN lain under f 21 Remarks) 0 h. 10 n. FILL SILT AND SAND
10 ff. 18 ft. WET SILTY SAND
4.Date WelIN)Completed: 3-2-22 Well maMW-30-S
n. n,
5a.Well I.icathm: ft. ff.
Energizer Greenville f1, ft. 4 e
Facilil)A)%vncr Nanrc Facilify ID9(if applicable) fl. ft.
3040 Evans St., Greenville, NC, 27834 fl. f1.
Pb%si:al Addmss.Cit)'.and Zip 2t REMARKS;
Pitt BENTONITE SEAL 4 TO 6'
(county Pastel hleftiirsaMion No.(PiN)
5b.Latitude.and Longitude in degrecsimitmtes/mcl'nds or decimal degrees: 22.Certification:
(ifssell ifeld,t)tle laillot iti sedlicicid)
N w Br .an..Ew n, 3/16/2022
Sigmturc orecrorud Well Coulm.lor ` Date
6.Is(are)the well(%): :21>ennanent or JTemporan
By signing ehis,fist,n,l herehr t•tr/if)•ehru Ow,i�rl!!.i')was{MMit•l i�[rnr/niclPrl in irCt'nrrlanCr
with d 4A NC.AC O C,ill/R7 nr d SA A'CAC QC 020j9 t1 i 1I Crmxrrrn ti.ti ctnrriirrefs runt rho/rt
7.Is this a repair ft)an existing well: E]Ye_S or MNo rnpyofrhicrermrllur%NenpmridedrothrstrNmrner.
if ibis is a fe)MIr,fill tau(`nr;em leell rn,urr(riintt htfotypsarkm anrd exploit the insane of the
rel."rircurtlrrN2i rrotordtt srtlian nr inn the hrerk of'thk for,n. 23.Site diagl'anl or additional iveil detail3:
You nrly use ilk back of this page to provide additional%veil site details or%veil
8.Number of wells constructed: 1 consuuciion details. You'mav also attach additional pages if mmessary.
For mandple i?lrekno M atNo-Heuer 3npj>r wells 0jV1,V wJrh the some enmetruclion.}•nn r.m
nuNnh one form. SUBMITTAL iNSTUCTiONS
9.Total well depth below land surface: 18 (ft.) '24a. For All Wells: Subndf this form within 30 days of completion of"well
For,rcadtipfr teedls list all delptht ifdifirrtn/('rr[nnpfc ;t6.'fl)'o,ud 2e MY) construction to the foltotsing:
10.Static water level below top of cawing: (ft.) Division of Water Resources,Inf it mation Processing Unit,
if„wiet teal is abort rasiar.um"4 1617 Mail Service(:enter.Raleigh,NC 2 7699-1 6 1 7
11.Borehole diameter.8.25" (in) 24b.For Iuiecl(on Wells ONLI' in addition to sending the forut to ibe address in
24a above. also subtuil a cope of this funn within 30 days of completion of well
12.Well construction method: BORED Construction to the following;
(i.e..aopm ratan•,cable.direct push ctc.)
Division of Water Rcsouroms,Underground.injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,e\C 276"-1636
13a.Vicld(gpm) Method of trst 24c.For Water Supply Nc Injection Wells:
Also submit one cope of this form within 30 63,sofcompletionof
13b.0hJnrhtion tape:__ Amount: well construction to the county hcahh dcpanntcn of the county where
constnictcd.
Fonn GAV-1 North Camlim MWrtrocin of Envirm uncia and Natural Resources-Division of walerReso%ron Revised August?013