GW1--03311_Well Construction - GW1_20230512

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WELL CONSTRUCTION.RECORD For ti enrol Use ONLY: • j '
This Conn can be used for single or multiple wells
I.WelLContratctar Inforntatiatt:
ILWATERZONES•.
Scott Hunt, Jr FROMTO DlcSrrnIt'tnarN
WcllCoMmoletName 0 ft, 15 ft. sand and water
ft. rt.
4561-A
NC Well ContrscfotCcnification Neither =IS.OUTER CASfNG[foe tnaflt-a°a d'niflil'OR LiNER tit aingleablef. '
FRONT TO • DIAMETER THICKNESS' MATERIAL
SAEDACCO Inc 0 IL 5 ft. 2" la: SCH-40 PVC .
Company N;m o 16 INNER'CASiNG OR.TUBINGVri6hcrmat caned-loop). ' -
FROM TO DIAMETER THICKNESS MATERIAL '
2.Welt Consuvstion Permit#; • R. • rt. .tit.
•
. Lirt all applicable,war permits(ia.County.Store.,Variowce.Irt(adct;elf-,..)
ft. ft, fix
3.Welt Use(shock wed use): 17:SCREEN
WaterSllppI Well - -- - FROM TO DIAMETER S LOT SIZE TIIiCRNF s i MATERIAL
C1Agrirulttical ,t51Giunicipal/PubliC 5 R. 15 R. 2" 4. O10 SCH-40 PVC
❑Geothemial(Heating/Cooling Supply). []Residential Water Supply(single) rt". rt. to,
(findustrial/Cotuntercial ®Residential Water Supply(shared) 'Ie GROUT •... __ " : .. . . - -
Friosr To 51ATEt'' EMPLACEMENT Immo&AMOUIST
Clirrieation 0 ft, 3 ft. Portland - Tremie
. Nou-Water Supply Well: ft. ft,
IiiiLfonitoring .ARccoveiy
Injection Well: ft, ft. '
l7 Aquifer Recharge QGennndwatcrRentediation -19 SAND/GRAVELPACK(ifimolicabtel •. -
❑A [infer Storage Recovery QSalintty t3ariictr FROM - To 1,tTE IAL i aMPI.ACENIF_NT Nt7tt(ln
4 S 4 4 R. '16 ft. Filter Sand #2
❑Aquifer Test- . ❑Stormwatcrfrtainagc
'R. ft.
❑Exiietitncnlah TccbnOtosv El Subsidence Control: 20:•DRILLiNGLOG(attack a dtlilioualsliectdif iecessarvt
❑Geotitenmrl(Closed Loop) OTracer FROM TO DESCRIPTION twbndarttnem,sun/nick tytx.pnin ii .dt.I
❑Geotltennal(1lealinglCaoliue Return) ❑Other(explain under#2t Reulalksi o ft. is ft, sand
ft: ft.
4.Date Well(s)Ctimpletcd: 4-7-23 Wtllm#12MW-10R ft. f4
Sd.Well Location: "m _
USCG Base-- Elizabeth City ft. ft. tl�n � p _ '
FactlityOwterName Faciiit)•U)p(if applicable) It. ft. I VL
1664 Weeksville Rd. , Elizabeth,City, NC, 27909 . ft. ft..
Pltv3>wafAddress_City-andZip _ .;'i^. Prn,CbrNui= lJi
,2 L REMARKS' rV V.:T4!'u'9
Pasquotank Bentonite seal from 3-4'
County Panel Idollificallon No,(PIN)
5b.1 atitude and Longitude in degrees/minutes/seconds or dexinu1 degrees; 22:Certification:
(Moen field,one.tat/long,is sufficient) -
N W c 'e —7 i 4/21/2023
Siatuture'OfCettifsedWellCo tor. Dale
6.1s(are)the-wcll(b)t 10Perurartent or .❑Temporary By:stand;tine farm.1 beechy comfy rhos the well(s)vary(were)cowiin clad to rtc'co,ionnr
with 1M NCAC 02C,0100 or 1M NCAC 02C,0200 Well Constrteriort Standards and Ova a
7.ist this a repair to an.existing well: ❑Yes or El No ropy of this record bra.been provided(o the"itrll owner,
if this lea repolr,ill cot kaolin well G»rKt,NCrlott I ifaonarloit amf e.vplaht rite nattier of the '
repair niftier 021 rnnarkssreiioo or on the bark of this fame 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Nntuher of wells constructed: 1 cousttuctioii details. You may also attach additional pages if necessary.
For rttailripli iafeettyn or non-Tearer supply wells ONLY with the saare constrireriosr,!lair can
submit one S11(IMCCfA L iNSTlICT1ONS
9.Total well depth below land surfaces -is (tk,) 24a. Per All Wells: Submit this faint within 30 days of completion of welt
For ma rlpk wells fist all depths if diti,restr 4xarnpir-3200'and 20100')- constniction to the folloui ngr
10.Static water level below top of easing 1 irk,) Division of Water Resources,Information Processing Unit,
i/otter level Is above casing.nu''+" 1617 Mail Service Center,Raleigh,NC 27699-1617
El.Borehole diameter:6" (in.) tab.For Refection Wells ONLY: ha addition t0.sending the fowl to!headdress in
24a above.also submit a copy of this form within 30 days of completion of well
12.Well construction method:Mud Rotary construction to the following:
(i.a.nub r..raanrl',cable.dinar push etc:, Division of Water Resources,Underground Injection Control-Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Cettiher,Raleigh,NC 27699-1636 .
t3;1 Yield Qom) Method of test: 24c.For Water Supply Si-Injection'Welts:
Also submit one copy of this form within () days of completion of
I3b.Disinfection type: Amount: well construction to the county health department of time county where
- constructed. !
• Form GW-I North Carolina Depanmena of Entree rctn and Natural Resources-Division of Water Rmou'tm Revised August 2013