GW1--03306_Well Construction - GW1_20230512

WELL-CONSTRUCTION RECORD Far[r�arnal Usc ONLY:
'Phis form can be used for single or multiple wells I j
i.Well Contractor Information: "
'14-MITERZONES-
Scott Hunt, Jr FROM TO Drtitif•MMOS
W01CorArdaurtlarno 0 R. 58 ft. sand�ald-water
4561-A
ft. fL
NC NVcll CormaciarCcriifrcation Nun-bir 15.OUPER CASING(for etulii-ea'wd'v 60 OR LINER of a N- bkl..
FROM TO prA ttF.T6R Trur'KNESS Ar-.'R 1AL
SAEDACCO Inc 0 ft. 48 fL 2" im SCH-40 PVC
Coalp uiy Nanu MANNER CASING 019r7 -BING('eoiiernual dosed-loop)
FROM I TO DUMETER I TUHMNES3 AIATERLIL
2.Well Construedim Permit#: R. tr.
lisf all rpp,lieatrlr.x�rN poniefts(ia.Cnunh•,S(utc,Uariarar•f!)reC04n rtr..J .
3.We Use(check well use): 17_SCREEN
WaterSupptyWelI: FROM TO MAM1IMIR sr.OTSt7E Ti11ClcNM I IMATRR(AL
OAgrictlinttal 01 unicipatiNtllic 48 ft. 58' ft, 2" Im .010 SCH-40 PVC
Meelliertrat(Hcating(Cooling Supply) Mcsidential NVater Supply(single) fr. fL in
©hidustriaUConuneicial ®Residential WaterStippl)(slated) 18 GROITP ._.
FROAf TO MATERrAL G+MPIMMMNTAteniol;AmouNr
❑hTi tian -0 ft. 45 ft. Portland Tremie
Non-Water Supply Well:
IMMonitoring QRccoi-cry rA
Injection Well: ft. fl.
CI,4nniterRcchtirge I7Grotmd{{:ttcrRcnicdiation 192,SAN DIGRAVEL PACK(it ap licabfc)
FROST TO - arATHRc{L EMPI.A(I-AWNTHtTInm
C1Arinifcr Storage andRCCoycry' [7551initV)3ariicr 47 R. 48 ft. Filter Sand #2
❑AgnifcrTcst ommage ft. ft.
MExpciimcntat Tcchnofog< 17Snb5idcncc Control
I0 iDRILLIING EOG(attach additionatibects if iucc mryl
OGemliermal(Closed Loop) OTracer FROM To DEsriurT10\mbr.hardneo su4'nkkq •n rite.cRA
OCroothemial(IIeatinglCaolIua Retum) ❑Outer(explain under 021 Renlatt s) 0 fL 59 ft, sand
rL ft.
4.Date Well(s)Cuhrpleted: 4-11-23 Weil ID((12MW-13R
Sa.Well iatcatlon: ft. ft. �-
.��; 5c
USCG Base - Elizabeth City - R, ft. �y
Faaility,mwncr Nan►e Facility IDk(Jf'gplWblc) R. ft. �ivrH M—& LOZ3
1664 Weeksville Rd. Elizabeth City, NC, 27909 R. fA ;;�n r;',y,
ll s
Physical address.City.and zip 21.REMARKS,
Pasquotank Bentonite seal from 45-471
cnnnly Parcel Widificallon No,(PIN)
Sb.Latitude and Long[tadc in dcgmolminutWseconds or decimal degrees: 22.CetTilicatintt:
(,if vicll field,orm Lrb7orr31g SidTieicrd)
4/21/2023
Signature orCeitified Well Con .tor Dale
6.TS(ate)the{{'ell(s): $1Pl`rnlanent OC ❑Temlrorar}' 11r;Aigning thin funs,1 hereby certify that the indlis!rsus(urn!)curtrtrneferl ur acconlancr
iviih 15A NCAC 02C,tllOU or PTA NCAC 02C•0200 µ'eff Consfrrtcrfon sranfardsand t w a
7.is this a repair to an enstingwell: ElVec or ®No eopr of(hlf record bqs-&rn pmrirkd ra;Ar roll aimer,
1f this'is a relwlr,fill var Ano:117r Nell cm rructloo 11 r1oamilon an nl,ap?aln(lie turrare of the
repair amlcr#21 reinar,L•r secliaa or ar the Sark of rhts foinc 23.Site dialtt atu or additional well details:
You may use die back of Uds page to provide additional tvell'site details or well
8.Nmullerof{~•ells constructed: 1 construction details. You tray also attach additionat pa&s if necessary.
Foritraftlple-lejecilon or am-mitar mpplr hells 0,4'LY rrlrh the saR(E constritedow,}ion can
sa b,nit one form. SUBMITTAL INSTCTTTONS
9.Total well deptit be[mv land surface: 58 ((1O 24a. Fdr All Wells: Submit this form within 30 days of completion of{yell
For rrealtlple ivells list all depths lfdill'erew(erno,pfe-3@:00'atul 2@ 1(k7y' construction to the foltaRing;
10.Static wetter level below top of Casing: 1 A) Division of Water Resources,Information Processing Unit,
1/naierlevel is above cadag,am"+" 1617 Mail Scn•ice Center,Raleigh,vC 27699-1617
11.Borchofe diameter.6" (iQ) tab.Fur Enicetion`Vc[ly ONLY: in addition to,sending tite fomr to the address in
24a above.also subnut a copy of this form within 30 days'of completion of well
12,Well coustmctiou method:Mud Rotary construction to the following:
(i_c.auger.ratan,•cable diw posh c(c j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636 Mall Service Center,Raleigh,vC 27699-1636
134L Yield(gpm) IMicthod of test: 24c.For Water Supply&19jeeection Wells:
Also submit one copy of this form ivithin 30 days of completion of
13h.Disinfection Type. Amount: well construction to the calmly hcalttl department of the comay where
constructed.
Fann GW-t Nonh Carolina Mp•,nln ent of Emirmrumin and Natural Resources-Dii'i;IOn of SVaicr Rixau Revised August_H►I t