GW1-2022-04472_Well Construction - GW1_20220509

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WELL CONSTRUCTION RECORD J (�� Fef Imcnial Use ONLY:
This form can be used for sigh of multipk wcUs
1.Well Contractor information:
t4:,tVATRR ZONES
Brian Ewing FROM TO DItSCRtt'Tlt N
Well Contratatx Name
4240-B fl fL
NCWcIICammctorCcniftcationNwuber 15.0iITHItCASING abrm+tfl int" ORLHOR i1-4 flcabk
FROM TO DTAMETER TMCKNES5 I MATERIAL
SAEDACCO Inc 0 (L 4 R, 2" 1 In, SCH-40 PVC
Canvany Nartic 16. G OR 771 IKG' llietmaf elowd-1
FROM TO DL%AIK.TER THICKNESS MATERIAL
2.Well Constractinn Permit# R. ft, tie.
List all appilrable well prror(Is(i_r..calm y,Slate,Variamr.P*6cn rlr.)
3.Well Use(checic well osc); 'SCREEN
Witter SupplyWelL FROM TO oraatMIR STOTS112% 1111100M MATaraA1.
OAglicutturll I�1Viunicipal/I`t►blic 4 R. 14 A. 2" Itp .010 SCH-40 PVC
DGeothermal(Heatin oolio Supply) OResidential Walter Su rL ft.
in
S SuAP 3 Pp�'(single)
Dlndusnial/C01tlnwrcial Dltesidential Water Su rs, O our ,
Rl1b'(shred) FROM TG MATERIAL ENGTACKMENT MEiHOD&AMOUNT
Ohirigodon 0 fL 2 ft. PORTLAND POURED
Non-Water Supply Well.
®1Nonilnrin OR=cmety
Injection Welt: fL f4
DAquifcrRcchargt WivundwatcrRcrnediation 19.'SAN1] kAVELPA(Xfif aimAkibtel
FROM To I tnATRIUAL EMMA.+m.NrMr7N 11
OAquifcr Slolttgc and Reco-miy (]Salinity 13aHct 3 R. 14 ft. FILTER SAND # 2
❑Aquikr Try ❑Stommvcr thing;
R. fG
Mxperimcntal TmIniologp 0S45idcncc Corrtrol
20..DRILLING LOG-(shach:riddi iotial sketsFirlweessan
OCeodieinua1(Closed Loop) ❑Tracer FROM TD DESCRIlrr10:cabr.rut aesl mcR s�a t c
0 fL 5 (L FILL SILTY S
OGeotllernlal(]leatin o' Returiq OOther(explain under#21.Remarls) F
5 fL 10 fL MOIST SILTY SAND TO WET
4.Date Welt(s)Completed: 3-28-22 Wetl1DpMW-13 10 ft. 14 fL WET SILTY SAND
511,Well 1A)CAtlnn: fL ft.
Airgas ft. fl
Facility/OwncrName Facility IDN ftfappli rlblel R It.
4108 US-117, Goldsboro, NC, 27530 ft
Ph53ical Address.Cat}•_and Zip 2L ttEMA1tKS
Wayne BENTONITE SEAL 2 TO 31''
Canuly Patcci(dettlirp-c0on No.(FIN)
Sh.l.ntilitdc and L ingitude in dizIp sllnimlteslscetinds or decimal degrees: 22.Certification:
(Itm ell fletd,mie I tt(lotq;Ix snffiriertt)
N W 8_ria,nl- -11 -f'1.g._ 4f1f2022
Sigmtwe ofCcniricawell Colttractor. Date
6.Is(are)the well(§).- EPertnanent or OTemporary fi nin tlrit form,I here ce dun the reel Yf Kvx fwem-J mmkiturled In amorddnce
N3' S 8 .( hS' �}' ft'.
ideA 1 SA NCAC 02C.01 W or I SA A'CAC(12C.02M Well Comirrtrriwt Standards and that a
7.is this a repair to an eai ttitc well: OYes or NNo copy of tlik record has been prrrirkd(I Me urlf manta.
11Ws.ls a repak.11l4mr Ant%iwi well cwwrivalort brfomutrdon and explaht rhe mrare of rile
relmir terrier 621 remora sm iorr or rut the bwk of this forme 23.Site diegt'am or additional well derails:
You may use die back of this pale to provide additional well site details of welt
S.Number of wells consiructed: 1 construction details. You may also attach addil onai pages if 1lecessary.
For ttttlldple ltt*ikan or nave-tamer AV*+.'ells ONLY iiii i die mme can
submit nae form. SUBJHI TAL I NSTUCTIONS
9.Total well depth below land surface 14 (ft.) 24a. For Alt Wells: S1rb1►ii this farm ti,,itlltn 39 days of completion of well
For ltrm0ple wefts flsr aNdeluhr construction to the.foRnwing: '
10.Static water level below top of casing (ft.) Division of Water Resources,Information Processing Unit,
if uuter Wef is above tvd ej$,use-+'• 161:7 Mail Serviectenter,Raleigh,NC 27699-1617
11.Borehole diameter:8.25^ (in.) 24h.Far Infc¢Iion Wells ONLY: In addition to sending the form to llie address in
24a abm'e. also submit a copy of this form within 30 days of completion of swill
1.2,Well constmetion method: BORED construction to the follcnving:
(i.e.aule-er.roinw.cable,dirM push etc.y
Dh'Ision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServlceCenler,Raleipji,NC 27699-1636
13a,Yield(}rpm) )lletltod of test 24c.For Witter Supply&lnloctfon Wells:
Also submit one cM,of this form %itbin 30 daysofcon,pletionof
13b.Disinfe►Ktan title: Amount: ._ will constriction to die colmfy 6.11th depencnent of the county whet
- con9mcted.
Feno GNV-t Nonh Carolina Depctttn,ent of E1n'ilottlt►ctu and.7nntrrl Resoumes-Division or Water R2Kurne5 RcOsed A11guA 21)13