GW1--04079_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For ltaermI Use ONLY:
This form cam tic used for cingk or nultipk wells
I.Well Contractor Information:
II.WATER ZONES
Brian Ewing IRON rr1 OVA TtIPTION
Well('otarsyor Nam: f. ft.
4240-B ft. ft.
NC Well Contactor('cnificatan Number IS.OUTER CASING(far muNitased wells)OR LINER 1W M[!Ralik)
IRON TO 1 Dt;MrTFR TgRI(AT ATM MATT Nt>,1.
SAEDACCO ft. n. I "•
Campus)Name Ill.INNER CASING OR TtBING ijntIb rmat clewed-loop)
Futtsl rti ' nitstlr1R r)n<ts•f'. I NIttrBSAL
2.Well Construction Penult It: 0 ft. 4 ft. 2 ie SCH-40 PVC
List all applirnhfe;tell prnwi (i.r.Conley Starr.Variance.Ga'Rfldt f
1ft. ft. t� l3.Well five(check well me): 17.S(RLLN
Water Supply Well: Ill 1 Div:wenn MM.OTJVT 1 TOKIOro. m41ral;I.
IIAgncultutal OMonicipal:PobliC 4 ft, 14 ft. 2 010 SCH-40 PVC
I)Geothermal(Hearin g Cook ft. ft. to,
n8 Supply) OResidcrxcll warn Supply(single)
1 i huduslrialContntercial OResidcn Mal Water Supply(shared) IS'GROOT
PROM TO MATERIAL.. j EMPLACEMENT METHOD t AMOUNT
D)mgation i 0 ft. 1 n. PORTLAND POURED
Non-Water Supply Well:
ft. rt.
K hkinitonnt ❑Reties cri —4 __
Injection Well: n. ft.
0Aquifcr Recharge ❑Groundwater Rcntedialion j l9.SANO.GRAVEL PACK Of aPlReaMt)
PROM 1O MATPBUI. ` FMPI.i('r.MV\T METHOD
0Aquifer Storage and Recovery ❑Sal mis Ramer 2 ft. -14 ft. FILTER SAND # 2
CI Aquifer Test DSionmsaecrDraimagc fi•_. It.
❑Espcnnicntal Tdhnobgv ❑Sdtsidcrcc Control ;a.ORILUNG LOG fatback additional sheets if uteetran)
❑(icwotltcnrml(Closed Loop) ❑Tracer FROM ' to o►s(RtrTION Rohm.rwrdeetw,w,St,wi.II m.^r.w',etc..*I
❑Geotltennai(lieatiowtooling Return) DOther(explain under 021 Reuwits) 0 (1' 5 R. FILL SILT AND SAND
5 Ir. 10 ft. WET SANDY SILT
•
4.Date Well(sl Completed: 6-1-24 Vt•Ii IDaECIT-IA-MWO2
10 R. 14 f.. WET SILTY SAND
Si.Well Location: u. ft. r�-- •-- e..',...w
USCG PFAS Site Inspection ft. fi, t l y,,`�
Factlns.Ow net Name Robb.ID0(if applicable) A. ri. J1'
1664 Weeksville Rd , Elizabeth City, NC, 27909 R. ft. 1 U ` �
Plnsical Adlfess.Cm.and Zip 2L REM AKars - . ..
Pasquotank BENTONITE SEAL 1 TO 2'
Counh RtrcclItkmiiftcttionNo tPINI
Sb.Latitude and Leaxitlde in de;Irtesimiautelisecnnds or decimal degrees: .2,(c riffle anon.
(Wise!'field.oac Fa log in sufficient)
\, Brian Ewing 6/21/2024
Stgna 1 t_cnilicd Well tehua.aor Disc
6.Is(argil the well(c): l31Prnnancmt or DTemporan S tN,I,tt.fly form f herbs rem dm eke nudist tsar(towel rvartrlfaed itr annndmrnr
loth 15t4 NCAC OW,0100 or 1 SA NCAC OTC.O100 WW1 Caratrw•tiar Swenlardc and rltttr a
7.Is('his a repair to an mistime well: Yes or KNo copy of IAA r.•:ord hat Free,ttt•.rw.d to she hell owner.
If this tt a rrpetir,611 on;ttuwtr it rll,[Rath!*r4.M Iufr)fayBh.M 11ICI eaplaPI Ow Ittt(Mfe of OM
repair alder 021 remarks so liner or on the hark of this forts. 23.Site diagram or additional well details:
You nta} use the bate;of this page to provide additional well site details or well
S.Number of web ou rwYed: 1 construction details. You may also attach additional pages if necessary.
For meetly&afferrlun ex atttt-Matt'+.apply n,.113 ONLY wuh the nRR,cmaalrterdoa wM"1"
tMbtmitone faro. SUBbMITTAI,INSTUCTIONS
9.Total well depth below land surfacc 14 (ft.) 24a. For All Wells: Submit this limo wohtn :tl days of completion of)tell
For moltipIr wells its,all.fruit)if drtereni lerumple-3@2tSt'and NIP ltSY construction to the following
II.Stake water keel below imp of maw (ft.1 Division of Water Resource.,Information Processing l nit.
if muter Irir1 n,Oros,meat.one"4.- 1617 Mail Sen lee(eater.Raleigh.NC 27699-1617
lt.Ile ebakdiameter:8.25" ()a.) tab.For Injsetiea Weijl ONLY: In addition to sending the form to the address in
24aabose. also submit a copy of this (oral within days of completion of well
I2.Well oauwnretion method:BORED coiisintction to the(Mims in g.
(i.e.auger.reimy.cable.direct push.dc.)
Oh Won of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 M Ml Sete ice('enter.Raleigh.NC 27699-1636
lac.Fur VI.awe Seppis &Injection Welk:
13a.Yield(1:11m)__ Siedsod ate*
Also submit one tayn oI IIIU form n MIDI to doss of completion of
tab.Disinfection lope: Amarrat: well construction to the coven} hcahh den-inmost of the comas where
constnlckd
Form GW-t Non)Carolina Ogrart eau of Em inmunem and Natural Resources-Division of Wafer Romans Res reed August 1'01 i