GW1-2022-03593_Well Construction - GW1_20220328

-WELL CONSTRUCTION RECORD For ln[cnml Use ONLY:
This fornt can b.uscd.for si ngk or mullipic wells
1.Well Contractor Infor oration:
LAVATER:ZONVS'
Brian Ewing FROM To I UP"WRIPTTON
%Fell Contractor Narm
ft. re
4240-B
r
-T3. UTP.R CASINGfor`aiuNi=aisiitr'eFls-ORUNER it.-a' ticable
NC t1CIl Gornt;lClorCC.nlfh"otion NlntbCt `FROM To 01A01FT,R 1111claNM, MATERIAL,
SAEDACCO Inc 0 fl. 25 (1. 1" to. SCH-40 PVC
(oolpany Ninte A&INNLtR f A'INC OR 771B1I�C atEnrrualcbsrd ti�f� ,.
FROM TO DLA\tETER TIIICKNEgg I SATERIAL
2.Well Construction Permit#:
last all applirable wrlf prrrnit.r(Lr.Crnmrv.Sine.Vaariwwr.Trf r6cirT eir.)
a. A. itx.
3.Well Vic(check well use): a 7:scRL!N
Water Supph°Well: FROM I TO I PIAM .TFR 1.OTS17S- I TRIC1CNESS I MATERIAL
ElAgricaltural L"lMuoicipa l ttblic 25 ft. 35 fry 1" in. .010 SCH-40 PVC
043cothemlal(Fle1lingrC00ho_R Supply) 1311esidentiil Water Supply(single) A. ft.
0 hudustriaUCommsrcial 011csidential Water Supph'(shared) 'IR'GROUT
FROM I TO MATERIAL I FMPI.ACEMENTMFTTIOn&AMOUNT
Dim ation ft. ft.
Non-Water Supply Well:
f1. A.
6 manitorintt ORccovcry
Injection Well:
OAquifcrltcchargc 043roUndn icrRcuicdiation .19,-SANbIC,RAVEL PACK fir `ilkablc .
FROM TO N+ITFNIAt. FMFI ACIAIENTMF"rn01r
1]Aquifcr$torlgearidRtrovrq' ❑$aliniq'HatriCr 23 ft. 35 ft. I FILTER SAND # 2
DAquifer Test O$tormivmcr Drainage ft. ft.
❑E%VcrimcntilTechnology OSRbsidcnccC;ontrll
'20:�DRII.IJe1'G'GOG(aitaeh'addflii»®I shre(s if nec�ti>ary
❑Geothermal(Closed Loop) DTracet 0 1 DFSCRiPTION fe0br,6ptdnrc st lYtmklr n�be.elrl
OGeothenual(tleatiggtpolitie Retuto) DOther(ex fain under#21 Remarks) 0 ft. 15 ft. FILL SILT AND SAND
r 15 ft. 25 to. SILTY SAND
3.Date iVcil(v)CongllCted; 3-10-22 Wel11O#DPT-OI-D 25 ft. 30 ft. MOIST SILTY SAND
Sa•Well Lfrcathm: 30 f6 35 ft. SILTY SAND MOIST TO WET
Energizer Greenville ft. ft.
FnciliiVMvncr Nin+c Facilhy IDk(if applicable) ft. ft.
IV ML
3040 Evans St., Greenville, NC, 27834 ft. ft.
P1tisical Addmss.City.and Zip 21:RFiItA1tKS"''
Pitt BENTONITE SEAL 21 TO 23' IrA
C.'ei+nxh' Pastelld•niiticalionNO.(PiN) Ir!FOf x
Sh.Latitude and J onRiTude in degrecslminutc0cconds or decimal degrees: 22.Certification-
(if
sell Pxcld,one l:tt+long i%Snllicicinl
N „ _ Brian EW n, 3/16/2022
StgruturofCcrtif>d14'c1lCorngctor r_ Dauc__ 2
6..h(are)the well(s): UPennanent or ZTemporvey M signing this helm,I hereh)e'rrlifr rhrtr the ierlh,.+l nvs fwrm)corauneted is rxrnrrlanee
with 15,1 NCAC 02C.010)ar 15A NOW 02C,02P0 Itr'lf CattArmetio-q Srntyfalift rfni111kq1(T
7.Is this a repair to an existing well: OVc. or Rt No r<»y Of this rrcotll 1utc henx p101-44-d tb)hr UVI!MOW.
1/this is a FrImir,fill rnitknown weU consnwtkrn hrfortnarion end e.rpinht the tu7rare if the
rgwir asder*21 rrmarkv srrtias or rut the hail nfthfs form. 23.Site diagram or additional well details:
You may use the back of.this page to provide additional well site details or well
R.Number of wells constructed: 1 construction delaits. You tray also attach additional pages if imc essary.
For tnulripJr inje coon o?nevo-wirer mplfy melts UA'1,T'xcfrh the some construcrlar,coo corn
.%uhn cane form sunmijaAL CNS"(!I T ONS
9.Total well depth below land surface: 35 (n,) 24a. For All Wells: Submlil this form wi(hin 30 days of completion of hell
For multiple wells list at)depths!j doerew ierampte-3@2010'myl 20 Hun comstruetionto the following;
10.Static water level below top of caring: (n,) Division of Water Resources,Information Processing knit,
Jf eviler k spl is al,m'r(,?Wfq,aw"4, 1617 Afail Service Center,RAleit;h,NC 276"-1617
11.Borehole diameter,2.25" (ia) 24b.For llda lon We11c ONLY: In addition to sending the form to Ilse address in
24aabove. also submit a copy of this font within A days of completion of well
12.Well construction nwthod: DRIVEN construction to the following:
(i.c.auger.retry.cable.direel pessh etc-)
Division of Water Resouro:6.Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,SC 276994636
13a.Yield(Upm) Method of test: 24c.For Water Suppiv&iniiectiinr W'clIs:
Also submit one copy of ibis form within 30 daysofcompletionof
13h.Disinfection type: _ Amount _ well constnrction to the county health dcpnmmcn of the county where
constructed.
Form GW-1 Nanb Carolina Depaninew of Enx ironflmu and Nantral Resources-Dig iiion of lWnicr Resototxs Revised August 2t113