GW1--02435_Well Construction - GW1_20240422

WELL CONSTRUCT[ON RECORD : For_tlxeriuil Use ON.LY:, •
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. This farincan be,used for single Or multiple wells',
1.Well Contractor Information: " f
'It WATER ZONES
Brian Ewing - IIUY1 TO IF.SCRtPI1ON
Well Contractor Natio ft.• ft. 1 ..
4240—B . • ;t� It. '1.
NC•Wd1ContmctarCcrlifrcationNtuillcr - ,tS.OUTER CASING(Tor ntutli-rascIf cfs)-ORLiNER(ifaiiypcubIc)
FROM- To numartER• THICKNESS ATATERIAL -
SAEDACCO .IL ft. ' . .in. . .
Coo' auty Nauuc . • . .16.INNER CASING.OR TUBING(geothermal cM cd-tonjtj '
PROM TO- DIAMETER. THICKNESS MATERIAL
2.Wc1t.Canstirretion Pgnuittl: . . . " 0. . f. 8 ft; 1" •'iu. 'SCH-40 PVC .
. .List ail applicable xr11 permits.fed.Couory.Stprc,;Variarcrr.frjerOUt er,.:f. R (f ,.
3.Welt Use(citeck well use): t9:SCREEN N i •
'water Supply Weill - . .- - _nnohi, To J DtAMETCR st.OTmlax Tittatut s. I.mAiEIttnj, '
. DAgriculnttal ' ClMuwcipaliPnblic • 8 ft. 18 ft:• 1" in .010 sea-40 I PVC
( Geothennat(Healing/Cooling Supply) ®Residential Water Supply(single) fL R in,
- .®htdustrjaliConmtefeial - CIResidential Water Supply(shared) . t acGRO1FT-
FROM . . TO sIATERW. EMPLACEMENT MEiHOD A AMOUNT
Elhiipation • . . .. . ft.. . ft. . •
. ikonWaterSupplyWell -
R. .ft.
®,Monitoring • . • , . . pRccoyery'• . . . -
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. Injection Well: - •ft.- . • ft. • . •
• D Agnifer Recharge • ElOtotindr aicr Rcnicdiaiion• -49.SAND/GRAVEL PACK(if applicable)" - - '
" 'FROM TO' • 'MATttRLO. • - t?NiPLtCiM NTSII iIOD
PAquifcr-Stotagc,and Rccorety i7Salinity Ramer . • 6 .f.• 18 ft.- FILTER SAND # 2 -
❑AggifcrTast OStomm rtcit}Ia oa ft. tf. '
t] zpetimcnlal TeClinOlo&V - f]$rtbsidcricC Control- 13n.,DRILLING'LOG(attach additional sheetsif nececwn•i
l7Geotliennal(Closed Loop) . [Tracer. _RION!• i TO DESCRIPTION(t»br.hardnc suRYniekiine.>:rsin?se.dt:l .
. • DGeodrennal(Heating+Cooling Return) ..DOther(eeplain under 621 Retain ) 0 . ,ft. .5' ft- FILL SILT AND SAND
• 5 •• ••ft• 10- ' f. SILTY SAND-
4:Date W.ell(i)Caniplele4 3-28-24 • .WCII mif TMw—,6 10 ,,ft, 18 ft. SILT CLAY.MOIST TO WET
Former-Edgeconibe Genco Plant • . ft. ft,• -
. Factlitgithtrer.Name ' • Facility ID#fit applicable) , . . . ft:. f( _ - ARr 2- .
6358.Battleboro.Rd., Battleboro, NC 27809 , .Edgecombe ' . n,• . ft;. 7;�,�rt * t
Count NC,- 27809 .. kf7V:.' rt+:; ; ; ue. ,�Piet
y, Physical Addtess.City.and Zip• �.2I.REhlARK.S ' L e'c Ce J:h.i •
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BENTONITE SEAL 4 TO 6', ,
Couoly - Parcel tdctitifrcation No,(PIM)
3b.L.atititde arid Iaingitade in itcgrcesiminutcslscconds ordecimal rtcgrttx 22,C•crtifieation:. •• .
Ore.:ell field,otk Itittlong iz s'dfielcid} . `�l' n .
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A NV •_Brian.-Etrig 4./3/2024 .
' - • - Signature.of Ccnifcd{kdl Contra—eta;• • , - . Dale -• .
• 6.IS(are)the well*.DFennanent .or �Tenlporan' - •Iii signing.Mir fom,'1 lrerrby rerrifc that iht well's)was-(Krrej cxm:raved hi re rotrlpwr •
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' - . wii'it 15l A'CAC.02C.0100 or 1511,NCAC'2C;MOO Well Coastriietiotr Staitdartis and that a .
7.Is this a repair to au.edsting rscll: DYes or GOND ,'rt pr of Thor record haa•bera ponided to:r1N yr11(ti mrer,
If;Wt.%o Pepxalr-fit qat kin n s.wdl cianstrarcrloa.brforouarlat and taplahr'rhe•-taarare of rho -
• J.—el/drum/ix ell roniark,arclioo or rm lire hid of tlris form.. , . . 23.Site diagt am'or.additional well details:' . . .
•You mayuse the bad;of this page'_to provide additional well site details or Well
S.1Cuiuberof wells constructed: 1 • • coustmction details. You May also attacttndditionat pages if necessary. .
For iiniltip(e irdecilnn ar oat-it'nrer supply welts ONLY midi die same consirurtlar,you rim
sat mu'ane form • - SUII14MI1'TAL iNSTUCTIONS. . ' . . . .
9.Total well:depth hetow land surface: 18 ((1.) 210.Fur ALL Wells:-Suhnd( thus form willrin•30 days of completion of Well "
For trrulrtpfa'icelfs'lis,aft•cpprksifdifliroit(exrrmplrt@••200'atu12010Kt),' ' . ' tonstmction.to the folicuing: I ';_ • • J.
iII Static water level heluss top of casingi-• ' '((I.) • Division of Wutcr Resources,Information Processing Unite •
!firma.lncl is above casfir,:ate"+" •: . ' . . 1617 Mail Service Center.Raleigh,NC 27699=1617 -
.. 2.25 : li
.• I1;Borehole diameter: '((n.) - 2�b.For infection WS1l ONLY: in addition to sending the form to the address in -• -
• ,24aaboi'e,also.submit a copy of this'fonn within 30 days'of.completion.of still
12.Well construction method: DRIVEN . ' - constmction to the following: • . - -
• c:aug.r.rotary.cable,direct push etc:} ,
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' • (t . ' Dh'lslon of Water Resources;Underground Injection Control Program. ' • '
FOR WATER SUPPLY WELLS ONLY: ' • • - • . • 1636 Malt Scrs ice'Center,Raleigh,NC 27699-1636 .
13a Yield(gym) b'letiuvd"of test: Ztc.-For Water Supply&Injectiaa• Wells:
- Also submit one copy of this fotnl,within.30,daysof completion of •
13b.Ui tinfe Ian typer Amount: well'construction to the county health dcp rnment of the..connh'.where -
constnicted. • ,
.FondGW.L NNanh Carolina D9tuquene of En'irOIUIs.ra and Natural Resources—Division of WaterRezou Revised August'Nrl3
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