GW1--04085_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For Nereid Usc ONLY:
no form cat be*sod for sink or nmlhipk wells
I.Well Contractor Information:
14.WATER ZONES
Brian Ewing MOM 10 DIN4'RIP I0
Well Contactor Nance rl, I ft.
4240-B ft, i O.
NC Well Contractor Ccnificsion Member 1 i,OUTER CASING?far asebi•eased nein OR LINER of M1phealth)
FROM TO I M;MFTFR Ttlt('k\rs. I MiTT$IM.
SAEDACCO n. n. M. 1
—
Cot N.rnr ani It.INNER CASING Olt TIOUNG. JatcI cd4wip)FROM TO DIfMF II(A\TER TIE ss MA11 IOU __
2.Well('nnstrnetinn Permit if: 0 R. 3 ft. 2 r• SCH-40 PVC
/an afhgmi'..r61.-...•11 lac ngu.ire.County.Shalt,Variance.1Wt es-.1 R.
ft. in.
3.Well I'se icheek well use?: 17.111711301
WaterSnppts Well: IRON TO RIAMITTn NOT sin: , Imtl t.sI' y1,tFRiat.
1.IAgncuhtual °MunicipaI'Ptiblic 3 ft. 13 IR 2 ia• O10 SCx-90 PVC
I IGeothemtal(Hcatingkooling Supply) °Residential Water Supply tsintdet
R. ft. is
i I bdustriallCommercial °Residcnaal Water Stpph tshared 1 W'QROOT
FROM TO MAtERLt1. EMPIACEMEST Mf11100 i AMOI.ST
❑kngation 0 n. 1 n. PORTLAND POURED
Non-Water Supph Well: R. ft.
X Monson ne ❑Rccas'cn'
6Jectioe Well: R. ft.
OAgwiferRecharge °GroundwaterRcmcdiiuion ItSANRIGRAVEL PACK(if applicable)
IRON TO Motsuiti CMMA(THrSTMCTW/n
❑Aquifer Stotagc and Recovery ❑Salinity Barrier 2 R. 13 h. FILTER SAND lk 2
❑Agafcr Test ❑Siomns:ecr Drainage -R. ft. --
❑Espetuncnsal Techwologt °Subsukn,..c Comm!
S.DRILLING LOG iallach additional sites if incessant
DGeothennial(Closed Loops ❑Tracer Mow TO DesCRIPTOri',Dist-.haNar..."ritv,n(Ipr.Frain.n•.,a i.._
❑Geothettnal(Fkm an:Cooling Return) °Other tesplain under 021 Remarks) o n. 5 ft. FILL SILT AND SAND
5 R. 10 ft. WET SANDY SILT
4.Date WCR(t►Completed: 55-31-24 W lei IDa ECIT-IA-MW01
10 R, 13 IL WET SILTY SAND
Sa.Well taxation: R. ft.
USCG PEAS Site Inspection n rt. ;:._-•".I `' . r
Facllny.OwttcrNan: Facilib ID#(ifapplicabkl
1664 Weeksville Rd , Elizabeth City, NC, 27909 n. fl. jli L 1 2 2024
Pin steal Addicss Cif,.and Zip 2L RZ)MARTLS ,S.f - , a-,-..•o/A;-.Z'+I-k••1 r
Pasquotank BENTONITE SEAL 1 TO 2' ('�3'
Df.t. SC.,-;)
Comri P,rcclIdcnidlc:a ion N. (Pr:i
3b.Latitude and l.nngirask in de1Irruminutra/sCennds or decimal degrees: 22,(-ertifrcatioa•
Orwell Acid.me tattoo i.....d h.,11
•
W _ Brian Ewing 6/21/2024
Smoot of Ccndcd Well Contractor Date
I..Is(errs the wcllise X Permanent Or ❑Tetlynarar ity sigmas im,fo,,w,f hereby.rrn(v dun the wrL1(sl nut(wrrrl naarrrrt'red ii,accordance
waft ISA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Weil Conrtrw'r(an Standards and that a
7.Is this a repair to an euistiug well: ❑Ya or ENu .-Lott,nfrlu.,n-,.rf ha,fw-n,prnruh•.!r.,.b. .rrn owner.
If Mil It a repro.Jai(ow 4o..wo well."owrio tom informsttort awl r;plain the main'a(rim.
repair tattler I21 remark,..r,Wort..r on die hart of this form. 23.Site diagram or additional w ell details:
1..n1 likes use the buck of this page to Im %ide additional well site details or well
8.Needier of wefts(omarut..ted: 1 :ottslrtt etion details. You teas also:mach additional pages if necessary.
For maliipr J.n.:n,n1,r"on-u n0r na 0 , ri,.ONLY with Mt.omsc01eawrsedon yua ring
aabmir.wlr fors,. SUBMITTAL INSTUCTIONS
9.Tetal well depth beim laud surface: 13 (f1,1 24a. For All W'dls: Subnat this limn within lit dins of completion of well
For mtdtipk oiU,list all,., •.if different tetantple-.1e200'and 2e1(MT1 construction to thc follnning
It Stake water ley el!whist lop of caflav (11.1 Division of Water Resources,Information Processing t nit.
ff.reuer kw/at ob.,.,asin� au"a" 1617 Mall Service('cuter.Raleigh,N(-27699-1617
11.Borehole diameter:8.25" (in.) 24b.For Inked**Welb ONLY: In addition to sending the form to tlic address in
Na abuse. also submit a copy of this form within ZO dais of completion of well
12.Well caestraction MOW:BORED coustmdion to the following.
a e.auger.town.cable.ditto posh dc.l
Di%iskin of Water Resources.Uadergn and Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 'tot.Neil See ice Center.Raleigh.NC 27699-1636
13a ttidd 124c.For Water Suppls a.Injection Wells
gpml NrHFad of sett Also submit one cops of this loan w ohm to day s of completion of
13h.Disinfection npc: Amount: well constniction to thc counts health dc(anment of the county where
constructed
FonaGW-t Noah Carolina Deponent of Ens itnlulctiu aid Natural Resources-Disaton of Water Emotion Wes tsed k gust Is.1;