GW1-2022-04210_Well Construction - GW1_20220419

WELL CONSTRUCTION RECORD For internal I rse My:
" 'flit fonn can be used For sf",ek or rm4tiplc nclls
1.F1V61t Contractor Information:
14;_ AITIGSLONES
Brian Ewing FROM TO nr,SClttPveOY
VVC11 contradlyr Nam ft, IL
ft, ft.
4240-B
NC Wdll Cabractor Can Mention Nvmbei IS*','OUTER C,&gI1r1G 'i'mull4diWll wi'(Is'OR LiIYFM if.tE..IkAble
FROM TO PTAMETER THWKIVM MATERIAL
SAEDACCO Inc 0 M 4 ft. 2" in. SCB-40 PVC
Cafopant Name - - MIN, Wd4 r
FROM TO DIAMETER TErICKNTS5 MATERIAL
2,With Construction Fermis
I!&afl applirabir uril penrits te_r..(-oamty.SW.tr.Varlarwe,Fnfe dMJ rfr.J � H
3.Wdl.Usc(ehMi well use): 17:;5[RL'EN
f',ROlMI TO 01AMATPR S�'tA,1TSt73; T/l1[YCNMS MATRRIA1,
Water Supply Well:
q ft. 1q ft. 2" tm .010 SCB-40 i PVC
l�Ag76GulttiTal t7lvlolaisipaVPnblic
Meothemtal Ieatin oolinS Supply © esidential Water SuPP5'(single) ft. fL in
MindusniallCoTrrmsrcial ®Residential Water Supply(sixtred) I&t3ROfl1- ..
FROM TO MATERIAL I EM�T ME790D A Al OLN'T
ObAgation 0 f. 2 fL PORTLAND POURED
Nor-Water Supply Well:
12monwri2 ❑Rapt fi.
injecilon Well: fr. it.
❑Aglrifsr"Recharge 1:30roundwalcr Rcutcdialion t9 AND VELVA (i fl, tcub'M
Pli M not#RrAt. rsiPs.n .Titf�TMt7r1 Ti
QA#uifcr.5tora_re alyd j=Nvty ❑Salinity Barricr 3 ft. 14 ft, FILTER SAND # 2
❑Aquifer Test ❑Stonm ver Drainage 11 ft.
❑8.Vrrimcnial Technology ❑Siftdcncc Control
-'20MOLUN1 LWOI G attsich d1�M'�I(tt31lA�.lSl Qit3-'�f 1bCS£<fJtTifJ'
❑Geothermal(Closed Loop) ❑Tracer FROM TO 1195CiRIMVN cobr.hananM e+,1VM0Ar AIA tft
❑Geotheniml(Heath .00tln Mum) ❑father(p3 air under 421 Remarks) 0 ft. 5 (1. FILL SILTY SAND
5 ft. 10 ft. MOIST SILTY SAND TO WET
4.Date WCU(v)Colnpleled: 3-28-22 Weti ID#OS-MW-1
10 a. 14 fL WET SILTY SAND
Ss.Well Location: ft. fL
Airgas FL ft
FwnilyaOil•rterNnm Facility TDO(if applimblei rx
fi. ft,
4108 US-117, Goldsboro, NC, 27530 R R
Pln-siml Address City.and Zip 2 L,1ti:M KS
Wayne BENTONITE SEAL 2 TO 3' DV?UBOG
f coley Parcel idet4ir=tion No,(Pill)
Sh.LaOlude ani)Ltirrgitnde in deg m;JmimrtcAcoonds or decimal degrees. 22.Ccrtifwatinn:
Ofineil Md.a+te 141oag is%idrlCknt)
W .8- rian,.E kng" 4f1f2022
SigaitM 0J`Ccrti:G:d Well CGlllrMOT Date
6.Is(are)the well(if)- SPermanew or ❑Temporary L�•sigaiiny,Nrk form,1 hereby vemtfy thrar the wrlllsJ war(inrrrJ eorninwfed 8r mrordance
with I5A NCAC 02C.Of M or 154 NCAC MC AZOO lVetl Commird n Starrl'ards wad 0w;a
7.]a thii a repair to an exh%ng well: oVec or tSNo ropy of rXT re9wnd hos!wren proritird to lain wrll oivnnr.
1f 0Is is a repair,fill,-at Jkrtirttw well cmAm revlon htfortwrrfirur mad a eptaht the[taro,"of rho
repnir wTdrr A21 rernarks.%rrAun or on the back of this form. 23.Site diWam or additional%-ell detnilc:
You may We the bact,of this page i0 proxide additional well site details or well
S.Numherof Hells consirttcted: 1 cottsunction details. You mar ajso auactl a�dilioltaE pages if rtxessatr'.
For JIMITIple irt}eelkat a tart[-utiner Mpph[Fells ONLY trirh rho arrtme s rftsiraeeriorf,yor,edM
.ctipmir mie form. SUBAIMAL INSTUCTIONS
9.Total,well depth below land surface. 14 (ft.) 24a. For All Wells: Submit'tlrs tom within 30 days of completion of hell
For arwhipir wrIls lisrafideptha lfdlflwem(example-3020'and 2@/Mr) constittction to the foiloning:
10.Static Water level below tarp of Basin#;: (p,) Division of Waster Resources,Information Processing Qnit,
tf venter level is oiwre v6skip..eft"+" 1617 Mail Service Center,ltelcigh,NC 2 7 699-1 617
E
11.Borchole distmetcr:8.25" (in.,) 24h, aft&tjv ONJIV: in addition to sending the form to lire address in
24a above. also'subta►il a copy,of [Iris farm within 30 days of Completion of%veil
12.Well construction m0hod• BORED construction Lo the fallowilke.
(i.e.mfper.rotary.cable direct posh ctc.1
Division of Water Resaurces,Utniergt'ound injection Control Program,
FOR WATER.SUPPLY WELLS ONLY: 1636 Mikil Se t i Center,Raleikilt.XC 23i5"4636
I3.L it'idd(MM) NlCM04 of test: Ur-For Water Supply&1nlcai6n.Weds:
Also submit one copy of thisf Mini within 30 days of c011101 Lion of
13h.Disinfection hVe:__ Amount: well constnsctictn to the county health deparnt=rt of the cmuttr wix-a
constmctcd.
Fenn GW-1 Noah Canfl na DeInnmem of Eavimi nsra and Natural Resom"s-Division of Water Resowces Rct•Ised August 2013