GW1--07235_Well Construction - GW1_20231108

. WELL CONSTRUCTION'RECORD l For Inertial Use ONLY:
This Cann can be uscd CJEr single or nusitipk wells
I.Welt Contractor Information:
• t:l tit:12ERZONES • i
Stefan Smith FROM TO b6SCntPitON
%Velt.Cor racierNanie R. ft.
3576A it. ft.
•NCQ'dlConttacrorCcnifcationNumlacr 1SJOUTERC�%S1NG3iorniutll=cas`vdi?11sYORLINERlifaji'flcablt);'..-
FROM TO DIAMETER 1 THICKNESS MATERIAL
SAEDACCO ' 0 ft. 6 It. 2 1.Ln. SCH 40 PVC
•
CaruputyN4u1t- , • ' -16:INNERCASINGOR-TTIHING.1_nediber`inatchi-ccd-foap) - - _. • -
FROM TO DLLMIETER THICKNESS MATERIAL -
2.Welt Construction'Permit-#: _ ft. ft. chi.
Leer rdl appli abbe well pet-mita(Le.Cnwrry.5iate,Variance,ItYa-i tit or.) - - - - -- - - ---
ft. 'ft, I:h?.
3'.Well.l)se(cheel,wdl use): 17:SCttE:E:N- - - -
Water Simply Well: FROM 1 TO - DIAMETER SLOT SIPE TRICK NI S I MATERttt,
°Agricultural - ❑TviunieipaliPublic
6 i1.:116 ft. 2 in. 0.010 SCH'40 PVC •
0GeotlteiR1R21(EieatiDglCaolio3 Supply) ®Residential Wafer Supply(single) iL IL i" .
I:3IudnstriallCoumtcrcial DRJsideutial Water Supply(shared) ' 18 GRo rr-- - - _-• - :'—•- -- -- '.•: -, -...
FROSI TO MATERIAL I EMPL10EMENTSIFEHOD di AMOUNT
❑irrigation_ ! -
0 ft 2 ft, Concrete 1Pour
Nou.Wtiter Supply Welt: , •
ft. it .
Mis,fonitonng 1J14covcry - ,-� -- _..• - -- --
'Injectlont Well: ft. ft.
°Aquifer Recharge - AGionndsrnterRetnedialion • . .;19 SaNINGIlAVE1.PACKta:appucabtil- - -
6•llOM- 10 - - 11A filtml. •-�ESIP.114(1:SwNrail:rilon
fAiptifcr.SEoiage aid 1?ecaveti•. []Salinity barrier 4 R. 16 N.. Sand #2
l7Agnifcr Tcst 17Slomn`atcr 13rainage '
iL ft. '
❑Experimental Technology °Subsidence Cor4ml
-211sDR1CLIING LOG(nuac6'additional'sbecls1fitecassirr-i- -- -
❑Geotlienlnil(Closed Loilp) ❑Tracer . FROM TO DESCRIPTION(robe.4anlucis,at nick 151ic.Mali a ddct
❑Geolhennal(HealinalCoOling Relunn)- ❑Other(explain under 0)21 Reworks) 0 -IL 16 fl; Clayey rsand
16 fL 20 -iL Flowing sands -
4.Date Well(s)Couipleled: 10-13-23 Well IDi#MW1. ft. ft. I _ •-,-'5u.Well Location: IL ft. i -
• ft. ' ft. f' ,! n-
Faclit),OisncrNome FacilitriDk(irapplienblc) ft. R. , - - i O —0— 202-3-
209 W'Saint James St. , Tarboro, NC, ,27886 n. it. : -,--, 7.,,,-, r(!l-,• '
Physical Address_City,and Zip ,21,.mom.Ries. . . C%'.v C.::'r j.:•+.7 . -
Edgecomb . I2 foot bentonite seal 2 to 4'
Csrnury Papa ldcriIrtie tlUn No.(PIN) ! ,
Sh,Latitude.and Longinttic in deglvcslntini t&scconds nr dccimul dcgrccs: 27,Certification:
(i1%0 fart,ass:Iati1u b Is&ictiJplioat)
35.896677 N 77.535731 w __igai6LvDf".
10/16/2023
Start ✓efcfld 1Vcll Cantetctar ! .Date
6.Is(are)the well(s): NIPermaiicnt . or ❑Terltpor.ity Hy signing Jhir form,I herein rerlift•that the inellist was-(wree)con hunted la accordance
with 1 M NOW02C,O100 or 154 NCAC il2C.0200 lreff Cons,rrirrion Standards mid hurl a
7.Is this a repair to au existing.iveIL CI't'cw or NMI • extraoj(Ail record bets•trims prneulyd Lath call earner.
if this is a reprlr,fill of kainvyi redd1 ce osJri trtdxrbrfarrnrirlrni anti erplahi he rwrirre of the
repair ruder 02 I reinarlssecgrnO ar-an the hark of this.form. 23.Site diagram or additional well details:
You way use the bacls of this page.to provide additional well site details or well
S.nmttberof wells constructed: 1 constmetioin details. You may also attach additional pages if necessary.
For multiple i u'ecrloa or rrrni-rimer supply'veils O,Y4Y Writ rile some canstrii't1wr y.1.41 Grin
sslinnit WIC farm. • . - . SUBMITTALiNSTUCTiT ONS •
9.Total welt depth heron.Land surface: 16 (ft,) 21a. Fur All Wells: -Submit this furor within 39 days of completion of well
For ninitipir ircllr list all depthsif different(crearpte-=l02(tir and 2110)4' constiuctientodtefollowing:
i•
10.Stank water level below top of casing: (ft.) Oir•ision of Water Rcsurirccs,Infurmatiun Processing Unit,
1f rater lettel is above casing;Bale"-s" 1617 Mail Service Center.Raleigh,NC 27699-1617
I1,Borehole diameter.8 l
(in.) 2-b.Forit[rctigr :ells ONLY: In addition to sending the form to the address in
24a above. also'submit a copy of this bona within 30 days of completion of[sell
I2:Well construction method: HSA • construction to the'follotving: f '
tie.aueer.rotary,cable.direct posh.eta) i 'Division Of of WaterReslfurces,Ugdcrground Injection.Control Program,
FOR WATER SUPPLY WELLS ONLY: I636 Matt Scti ice Center.Raleigh.NC 27699-1636
1
13:4 Yield(glEnt) Method of test: 74e.For Water Simply&Injection,Wells:
Also submit.onJe,copy of this fonts Within 30'daysof completion of
isle.Disinfection type: Amount:
well construction to the county Health de11:1nmesJt of the county where
. conslnutcd.
Fonts GkV,l North Carolina IX-patunera of Environment and Natural itesotuces-Division of Water Ravice Revised August:to 13