GW1-2022-10433_Well Construction - GW1_20221116

WELL CONSIROCTION RECORD, Tqr lmnmi Use,oriii^.
This form sari be lrscd frirshigls ai mulliplc nstls:
1.k4`etl:Coutrictorlii�orniatlott:
14.11ATER ZONES
Brian Ewing FRONT, 1.70 POiCRIRTION,
W0(6n6dorMime ft. Ft.
4240-B n. ft.
ItTC.Wcl]ContmclorC'artifbmtionNwri6ei 15.OUTER CAS NG tfor'mulikaselCReflsl OR-GiNER lff:u i licahkl
FROM. TO DL•1.11E.TER: TH1CIi.VE.", N-.T 1IAL
SAEDACCO Inc ft.. IL is
Contt,:rar.Nanrr 16.INNER CASING OR TUBING •veotherm-al chiced-Itmit
FRONT 70 101,01ETER- THICkNESS I h1ATERLM1L
2.Well Construction PF1m1i1t#. 3 TOCft. 25 Ft. 1" m! SCH-40 PVC
1.irPtrllnpliticahle v,-efl pe'rrnit;fi,a.GnunttVSfritc;•Ynrin,rcr.1f�2Li)ul.rrr,:J
ft" Ft. m
3.V4ril.iisc(choct.ri°ell usoJ: 17 SCREEN
WaterSnlilllti Well: FRONT Tl? 1 DrANIETFR 1 510'TWX TT11"%'F55 NIATFRTAL
C Agriculttlrai ❑16funicipalf blic 25 ft, 30 11. 1"' 4 .010 SCH-40 ' Pvc
OGeo(hemasl(Headng/Cooling Supply) GiRtsidential 4`ater Supply(single) A. rl
QlndustriaUConutterciA Mtsidtntial Water Supply'(slmrcd) is.GFRONTROUT •TO 51ATERLIL E\1pLAC£\1EyTh1E1110D SA\]O[lNT
❑Irre pficu it. rL
N6u-R°aferSupPl},Well: � r�
mhfanitoring I711cca vvy
111jeo[on Well:
bA,nt.ifcrRechargc Qdramidl m: rllamediation 19•SANWGPL ELTACKlirsl,t;cunrxy
� • - 'F"ROi1 70 � DiM1TF;ttLM1I, F:�tPI A(:F:11F:YT�I}:Tr101r
C1Ai)utfcrStoraacanditccovciy' i7$alinih Hlliact 23 ft. 30 ft. FILTER SAND # 2
QAtjtlifcrTcst- O5miutll-atee bnlii Ji1'C ft. ff.
❑l xperimcn(al7hhno(agy ❑fillhsidcncdt oWT.ol
70:DRiLLi\G`LAG(attach additions)streets if ncccscanl
❑Qvdienmal(Closet[Loop) ❑Trager FRONT To DESCRIPTION'(rnbr.l ardricn.wirmek ty vc,wWolwA!,ek:)
❑Gwiltennal(Heating.CmlingReturn) ❑Adler(explain under 921 Retnalt s) 0 it. 15 It. FILL SAND/SILT MOIST TO WET
15 ft. 30 fL MOIST SILTY SAND
4.Date F1?cII(s)Ctinlpleted: l0-io-22 I'vill lD#A6TW-D-01
ft. ft.
ia:WClI Ltrcrtion ft. fL r u/ J
T A �• t
Seymour Johnson AFB ft. fL FaclitykimcrNunrc fit Facilfly IN(kapplicablej Iv
1050 Wright Brothers Ave., Goldsboro, NC, 27534 ft. fl
'G
Plrysirid Aiiili�ss.City.nerd Zip -21:REnL�R1CS Ft 1
Wayne BENTONITE 21-23'
Cttmtll' Pxcel la mlirtcilipu No,(PI-N)
atitirdc anal 1d611etude in dggrccs?ntinutcs?seconds nr-dccimal`Ilcgrecs
22.CcitifiWdott:.
(lfilcli ff`tetil,•t�jr�I rU7at9 if'cicfiiGicld)
W .r 1�1 .EVY is 10/4/2022
glu SiturcarCcltifrcd W'cll e(i t" tdi- /Vi Ddle
6.iS(Rte)the 1fe11(5}t 'J1Ltit7lliltlettl or �7emilorar}'. gr sgnhg j6h firrm;,l herrLr rerrifC Mar the irellfs)P.-my rrr)rgnYlrlrrred hr aveardance
ri irlt 15A NCAC 02C.01 or I SA MCAC 6ZC,6200 ll till Goiritrricdar Seandarrfa and dust a
.Is this a rnpaiir to an txi iting v'cli: ,Mcs .or O1Vq e is of rliAs rrc+,rd lr"esf�nr r,fnt,rf d ra,i s. n*lt awner,
tfaltfri$,artl\rfr,t1f1tm "rartxw arid r.tpbbiTbenr;rnreofthe
rr:w"rreirirl�-oil rrnv:rlr:rtr.•tiwrs ne m fti l e'A of this•farm. -23.Site diagram or additional welldetaiils-
You[1w use ili-hack of this page to'-provide additional tc'ell site detaili,or wiell
8.N0otUerof Wcl6 colutructed: 1 constmetion derails:'You may a also:atlacb'atdtlitioaiat pates if necessary.
For lna,frir.le k0etirkan mr rani-e srr supAv i.Hb-t7h'LY midi rhr.samr coarstrarrlio,p}'oa+c trt
.rarwretaaarl4rra: - SUBMITTAL iNSTU T70NS
:7bfnl will.depth hWtoti,land sllrfuca.. 30 (ft.) 2aa.,t ti"r Alt tl`ellr,.'Siiblidt Ilds Fnini ti�thin 3U clays sf compictiria of Weil
Fia t+ivftiplr ii�ctlx�'Per+atl 4gulas t tf i're'ait tcxarrn to�i�ea 'crruf tak�ry' ns(nsciig6 to the fpftptitiing:.'
10.St' Water level Below top of casi kWt (ft.) Divisian of Water Restrurt6,Informaitian Praeessing Unit,,
if wd,w level 1,mDove,rxa#4x bse"+" 1617`A1alI Stri iec Ceritcrl.R rlcE�ty;vC 27G9'J-1G 17
tl.Borebolc diamct&.2.25" (iD) tab.For Tulcctlnn Wtlic ONLY::Fit addition to sending Ilt2 foml to d)e address in
24a abore..Aso'suhnut a Coln•Of tiris.fonn Within 30 days'of c6lnpletidn of tall
12�Wcllcunstructiou method: DRIVEN Lonsim' dion to'dlt 6116MIle,= "
6c..31IgGf.r1F1.7i?•.C-IItTIC�ai74Y1.1Nr5(l dc:) ., -.
'Division of Water Resources,Utider�ond tnJcciion Control Progmfil;
T01tWATER SUPPLYINELLS ONLY: I636 htaEl Sl n9cc Center,Raleigh,
MTC 27694636
13a;Vicki(>;pm) ,lfctliad of test 24c.F(ir Water Supply&Injection Wclls:
Also subriiit one copy of this form;%within 30 daysof'gonipletionof
1*bisinficetion typiet• Atn6unt: -.__-. Well coll•5liliction to tllc county hcaittr dcpartmcnt of the c0iintv.r,9tam
Constmctcd.
II
Forw,islSr-L NorthCaralbiaDepmutientofEnviraauucruandNann•,ilResources-Di hionefR`alcrResatrm Revised August2ti13