GW1--04082_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For'teem!live ON1.5'
T1r,'form can Is iced for cin;;k' „audnr a rrclls
I.Well Contractor Iofonnatnor
Ia.WATER ZONES
Brian Ewing FH(/sl ur Dfsrairt1ON
Well Contractor Name O. h•
4240-B ft. ft.
NC Well Contractor ccni1m,I,o nrntsr 15.OUTER CASING Oar mehl-easid wells)OR LINER litNimble)
FROM ' tO 1 MVMTTTR I TNICIy\TSS M61TMO
SAEDACCO h. i h. in.
Conpanr i..rnx ta.INNER CASING OR111WVGJembrreaLteisev4lwp)
THOII r' 7O MA,AtETFN .~-tllld'ANEaS M\iERIAL
2.Well Construction Permit#: 0 h. 3 ft. 2 IL SCH-40 PVC
Liu ufl q rla able urn permits fa-e.County .Shan.Variance.IIre 0Crt rlr.l - - _- - --� '
rt. R. �.
3.Well I-sr wheel:well owl: r
7 .
11118
'Water Supply \►ell:
NOM TO DIAwTFR SLAT WE T111(1CNt?tS MATERIAL
LIAgricultural OMunicipal.Public 3 ft. 13 ft. 2 010 SCH-40 PVC
11Geothemal(Heating.Cooling Supply') OResidcntial Water St h' h' is
Supply(single.;
-_
I ItHdustriatConuncrcial OResidcntial Water Supply(shared1 IL GROUT
PROM TO MATERIAL. 1 EMPLACEMENT METHOD a ARDENT
❑Impatlon 0 ft. 1 ft. PORTLAND POURED
Non-Water Supply Well: (
N nMo onne ❑ n Rcco\r .__ 4
Injection Well: n_ it I
rI Aquifer Recharge CI(imundwatcrRcntcdiation J is.SANII(AtAVlLPACK(tfa , ie)
now TO it ATRIUM. rMH.Ari it NTNfT,(/D
❑Aquifer Storage and Recover ❑Salinity Ramer 2 ft. 13 h. FILTER SAND # 2
❑Aquifer Test ❑Smnttwaner Drainage h. ft. —
❑E'ap nmaual Technology. ❑Suhsidctac('roam!
20.DRILLING LOG(attach additional sheets if armours 1
❑Geothcnnal(Closed Loop) ❑Tracet VROM TO Drx RIPTION Love,Marche..,uinnuL nr pr.Irma vw.tit
Gl of ennal leating(oolillr Return) 00ther)explain under t21 Remad:st . 0 tt. 5 ft. FILL SILT AND SAND
❑
5 ft. 10 ft. WET SANDY SILT
4.Date WeN(vl Completed: 6-4-24 Wdl mpECIT-AR-MW 0 3 10
11. 13 rt. WET SILTY SAND
i
Sa.Well Location: ft. h.
USCG PFAS Site Inspection R. ft, s" ,. L•1,V
Fa iht Orono-Naar Facility IDa(if applicable,
f1. R.1664 Weeksville Rd , Elizabeth City, NC, 27909 R JUL
ft. 1 2 2024 ,
Plnser!Addocss.Cin.and Zip y
7R R[MARK.4 11%�:RY•.,`l '9•rr5lii''t ).til
Pasquotank BENTONITE SEAL 1 TO 2'
pt;::13LA9
('onnh P.arccl t.kntdtcrtion N.I IPIN I
`h.'Altitude and Inngirwak in degrees.minutes:Seconds or decimal degrees: 22.(rnitiranon:
urwrn field,one la61aate.....done)
N W Brian Ewing 6/21/2024
Signature of Certified Well Comcwt.r Dale
I..Is(area the wends): X1Pennanent air trnt(aran
Nr Abviing Jhu harm.1 here/a arrnfy friar the argfsl two turret ermrtrlected in aerordomr
wit*154 NOW 02C.0100 or 154 NCAC MC.0200 Weir Constro tioa Standards and rhea a
7.la tits a repair to an esistieg wen: .:,1 es or X\o ra>t.."(Mir rrr,mf haw been(r,ravd•d rn Me urn owner.
if am III a arpair,fill ow two.....if woo*nab:forrourrar,I oe.)rypiam Ow otiose,'r r„
repair under 021 remarks section or ern the hark..!Phi..fury. 23.Site diagram or additional well Mails:
You own use the back of this page to proslde additional well site details or well
8.Number of wells as alrected: 1 cotutru:ion details. You may also attach additional pages if tres:essan.
far malr.pk mjea.Non or ram-sous umph urlls ONLY a,01 rho Wale Constr fenaw r.,a...a
soM,lita.aw form. SUBMITTAL INSTItC11ONS
9.Taal wdl depth blow lam iwrfac: 13 (9.1 24a. For AN Wills: Submit this I•onn within 10 days of completion of well
For nalripk relit nu all depth:ifdifferrnt lr.taarpf-1' 200'and 2%1001 construction to the folbwing-
lu.Static water level below top of c*SiS$ (MI Division of Water Resources,Information Processing l nit.
tr moor 7rrr1 n Idar.rr.aslnR.ere"a." 1617 Mail Service Ginter,Raleigh,NC 27699-1617
I I.Borebele diameter:8.25" (in.) 2lb.for inketlen Well,1 ONI.V: hi addition to sending the form to the address in
24aabrne. also submit a cups of this form within 'k)days of completion of well
12.Wen ceostrwd ii method:BORED col unucliun to the following.
I I c.auger.rota..cable,6m*push.de.l
Di%Ohon of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: l634.Mail See ice Center.Raleigh.NC 276941-1636
13a Yield 24c.Fur Rater supply A.Injection W'clh:
(>AIui _ Method of twist:
Also submit oak copy of this faun within ;a day s of completion of
lib.D(siafectiea type: Amount: well construction to the came health depanmcnl of the county where
constructed
Form GW-I Nonb Cambia trienniums of Ens nomlatiu aid Natural Rcsourcea-Division of i.ur l Entree Ho Ise.] August v.I;