GW1-2022-03591_Well Construction - GW1_20220328

WELL CONSTRUCTION RECORD For Intental Use ONLY:
This form can M osed for single or muhipk s%rlls
1.Welt Contractor Information:
n;44.%VATER ZONES.
Brian Ewing FRosf TO O►_SCRIPTIO\
%Pen contractor Nam A. A.
4240-B
NC%tell Contractor Ccn ificat ion Nan bcr ISrOl1TFR CASING(for"eiuHi eased ieFls'OR 4TN£R if a'"lknhk
FROM TO 01,%mrTER THICKNESS MATT,RIAI.
SAEDACCO Inc 0 it. 25 it. 2m in. SCH-40 PVC
Congrarg•Nauw 161 INNER CASING OR TUBING Jeotlterrtiiltiuudaon •
FROM TO DUIIETER THICKNESS SIATT.RIAL
2.Well Cnnstivction Pco-mit N: ft. ft. m•
list all applirable well permits(i_r.Comit.y.Skive.Variance,lffaticn eie.)
ft. ft. in.
3.Well 11sc(cheep well use): 17'SCREEN
Water Supply Well: FRoM TO DIAMETER Stt07-Sl71: I TIIICKSRSS I MATPRIAl."
t.7Agricultural 0municip:illhiblic 25 ft. 35 ft. 21, irk. .010 SCH-40 PVC
1310eothemlal(licit inpCooling Supph') ORcsidcntial Water Supph•(single) A. ft. in.
01ndustrialfContntcrial 011csidential'%Vi(er Supph'(sikated) 18.GROUT
TO ?fATFR1AL F.MPI.ACFMt1T M17Tt10U R AtlfOti\T
01ni ,tion 0 it. 21 ft. PORTLAND TREMI
Non-Water Supple Well:
151VIonitorinr ❑Rccot'cry
injection Well: ft. ft-
❑Aquifcr Recharge 06rotlndunicr Rcntcdiation 19.SANDK:RAVEL 1'ACK(if 'ilkable) `
FROM TO MATE10,41. EMPI A(`i:M►:�T METHOD
❑Agt►ifcrSiorigc and Recovvy ❑Salinity Rimier 23 A. 35 ft. FILTER SAND # 2
❑Aquifer Test ❑Stortimmier Drlinigc A. it
❑E\perimcntal Technoloa ❑Subsidcacc Cardrol
20:DRiLi NGLOG(sit xh'iiddUionalsheetsifntccimly
❑Geothennal(Closed Llwp) ❑Trdcet FROM 'TO OFSCRIPT1ON ftubr.hpedn%%*,l,.R'mrkh . n 3re.44t.)
❑ceothennal(Hcatin'Cooline Retnm) ❑Other(ex lain under 021 Remarks) 0 ft. 15 ft. FILL SILT AND SAND
15 ft. 25 ft. SILTY SAND
4.Date Well(s)Completed: 3-2-22 Well tD#MW-30-D 25 ft. 30 ft. MOIST SILTY SAND
$y-��'191L1t[athln: 30 ft. 35 it. SILTY SAND MOIST TO WET
Energizer Greenville ft. to. R��1 0 /�
FacilityaO+yncr Nunac Facilny 1Dk(if applicable) 0. ft. —lV ° \�1�
3040 Evans St., Greenville, NC, 27834 ft. ft. MAR 2 8 2022
Physical Addmss.City.and Zip 21 REMARKS-
Pitt BENTONITE SEAL 21 TO 231 (f1f0fWgbtkM Pf000G%i tg lJn*
(:antsh 1'atrel Ideulific lion No.WIN)
Ski.Latitude and Longitude in degrecslminuteslseetinds or decimal dcgt ccs: 22.Certification:
(if cell field,One Iatlong i.stdtiekitn
W Brian Ewing 3/16/2022
SignlRer:ofCcnifi.^dWCl &nlm.tor Date
6.is(are)the eell(s): 2Pernianent or oTemimran' Ns signin}•this(cinn,l frrrrl r e'rrlifr thew rhr,e•ellfs)sews(Nrnr)ronvinteie d in aecordenre
with 15,1 NCAC 02(7,01lk)or 154 AICtC 02C.O20A Well Cimstrn rion Srandarifs tile/lIPT,a
7.Is this a repair to an existing well: oVcc or XNo ropy of rhis rrronf hashers pim-ided to rhw well ratter,
if lh(s is a relxdr,fill two:knoitvl well eoratltn"then lnforowdon and e.t'plahi the narure of rite
relwir torder021 re-marks.vet-fi a or on he hunk of tlih form. 23.Site diagrain or additional w0I details:
You may use the back of this page to pfoAde additional well site details or well
8.Number of wells constructed: 1 consimclion details: You inat•also attach additional palvs if necessan'.
For m ldple i,rleerhwn co at-vi-rarer mpl4Y wefts OA'l l'tridi(he some eonstrurdon.c:}ir son
.,ubn it am form. SUBMITTAL-fNSTL1C-310NC
9.Total well depth below land surface: 35 (ft.) 24a. For All Wellx: Subutil this forni within 30 days of completion of well
f'or widilplr wells fist all depths ff dlffi•rew(exaruple-3@209'tatd 20 09) constnuction to the follo%ving
10.Static eater level below trip of casing: (ft.) Division of Water Reoources,Information Processing Unit,
Ifietwer lerel 15 akwe rasing,use^4" 1617 Mail Service(.enter,Ralcigh.NC 27699-1617
11.Borehole diameter:8.25 m (in.) 24b.For Inkrlion Wells ONLY: In addition to sending tic fonn to live address in
24a above. also strbmil a copy of this fonn within 34 days of completion of well
12.Well construction method: BORED constntctiou to the following:
(i.e.anpr.nose,•.cable.direst push etc.)
Division of WaterRecourccs,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,wC 27699.1636
t3a lidd(gpm) Method of tit 24c.For Water Supply do InjectNm Wells:
Also submit one copy of this fonn within 10 daysofcompletionof
13h.Ui+infiYKiongpe:- -_- Amount well consinivion to the county health depnnmcni of the countv.ehete
constmctcd.
Fonn GN-1 Aonb Catolhu Dcpannicntof Encimitowtd and Natural Resources-Division of%Water Resources Rcviscd August_N)13