GW1-2022-03595_Well Construction - GW1_20220328

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WELL CONSTRUCTION RECORD For ltacrurd Use ONLY:
This fornr can bo used for singic or muhiple tails
1.Well Grotractor Information:
I4.WATER ZONES
Brian Ewing FROM TO V DKSCRIPTION
Will Corcrictor Nana I A. n.
to. A.
4240-B
NC Well CamnrclorCcnifnationNunlbcr 15 OtiTPRCASfN1G.fori+iuhictiselretls ORLiNER K.a b1kaAk
FROM TO OLAOfETF.R- THICKNESS 31MT,R1AL
SAEDACCO Inc 0 (1. 10 n. 1" in. SCH-40 PVC
(<ortgtauy Nawc MANNER CASING'OR108INGlieoiAcrrnittlurcddonp
FROM TO T DLA\trTER I THICKNESS MATTRIAL
2.Well Construction Pcrmit#: n. rt. in.
List all al7tli.-rrble tnell pcnni)s(i.e.C u,rtV.Sure,Variatree,frixBart etc.)
3.Well Use(check well use): 17 SCREEN,-, .
Water Supply Well: FROM TO 0IAMF.Tt.R SLOTS1%F. TulCKNr11- I MATERIAL,.
OAgricultural Omunicipalllhtblic 10 n• 20 ft. 1" in. .010 SCH-40 PVC
i 43cothmt cal(Heminp}Cooling Supph') ®Residential Water Supph•(single) ft. to t°'
01ndus(rialfConmlcrcial 01t sidential Water Supph•(shared) FROL,NI To dIATERIAL EAiPtACEMEYT Mrrnon.c AMOUNT
❑lrri alion (I. rt.
Non-Water Supply%Veil: ft. tI.
(Monitori%, ❑Rccovcry
injection Well:
ClAquiter Rcclharge MJroundu-nicr Rcowdi:Rion 19.SANDIGRAVEL PACK Iif `ilicabte
FROMI TO
❑Aquifer$Iortge and Rn-otrl}' ❑$alinin Hamer MATERIM, EMPI.ACt N1;NT M/TH011
8 A. 20 A. FILTER SAND # 2
❑Aquifer Tcst OStornnsater Drtinaae
❑E\:trdmcntal Technology C]tiRfisidctwc Cotamt
10.DRILLit1G t.OG(attach additional sheds if ftmCssnn
❑tstvthemral(Closed Loop) ❑Tracer FROM TO OF,SCRUMON(color,hardnvis wWrttek tv in Svc.Nc.7
OGeothellual(Heatinr lCoolir a Return) OOther(explain under#2 i Retua&) 0 ft. 10 ft. FILL SILT AND SAND
10 ft. 20 ft. WET SILTY SAND
4.Date Well(%)Completed: 3-11-22 Well iD#DPT-02-S ft. n.
5a.Wt•II Ulcathm: ft. ft.
Energizer Greenville ft. to. a
Faciley,Dwrrt Nunn Facflitt•1D8(if appliulblc) to. ft. g't �
3040 Evans St., Greenville, NC, 27834 ft. ft. Ulli+
P1nsical Address.Ciq,apd Zip 21:REMARKS"
Pitt BENTONITE SEAL 6 TO 8'
(Amrq' Parfet ldtalirte.9liUnN(,.(PIN)
5b.Latitude and Longitude in degrecs/minutcshwconds or decimal degrees: 22.Certification:
(if sell Picld,ota i:dl oq-is erdric%un
N W B.rianr.Ewi'n 3/16/2022
Ewing,.--,
Sigruiurc ofCcniF d Wctl Contra nor Dane
6.is(art)the well(a): OPermanent or ZTeml)orary M-signin)•this,lunn,l herehr r'retifi•dua the tryllfsl ttws:(wrir)c-onitnicted br aecordenr'e
work 15,1 NCAC 02C.01(k)rn•154 A'C.tC 02C.0209 WWI Conorot-rirn ctoikkuls and that a
7.is this a repair to as existing Well: ❑Yee or Elio erf)y njrhis rrrant has Nrn pmride4l to the styli moirr,
If this is a filth,fill evs.troovi well conAnirdan htforrwrlon and esplohl the mn.re of the
repair amlrr 021 remarAs-sr"rim or an thr hnri of dd.v form. 23.Site diagram or additional well details:
foil may use the back of this page to provide.additional Welt site details or%veil
R.Number of wells constructed: 1 couslluclion details. You`tnay also imach additional palvs if necemry.
For mrdtlplr infection tsrhide-eau r sup#y wells ONLY whh the some eotrsirurr an.you con
w0mit per loan. SUBMITTAL I NSTtiCTIONS
9.Total well depth below land surface. 20 (ft.) 24a. For All %Veils: Subrtul this form within 30 days of completion of well
For intihiple wells list all deluhr if dlffrrent fcxmnplr•J@200`oral 20IMI construction to lite following: '
10.Static water level below sip of casing: (n,) Division of Water Resources,Information 1Protessink Unit'
1f nwtet level It shove easing,toe"+" 1617 Mail Service Center,Raleigh,NC:27699-1617
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11.Borehole diameter.2.2 5" (in.) 24b.For Iniection Wells ONLY:f In addition to sending(tic foml 10 the address in
24aabove. also submit a copy of,[his fonn within 30 days of completion of Well
12.1Vcll construction method: DRIVEN Construction to the followine:
(i.e.auger,rmfy.cable,direct push etc.)
Division of Water Resources;Undcrvround InJcctitin Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
13a.Yidd(gpm) Method of test: 24c.For Water Supply&injection Wells:
Also submit one copy of this form W-ilhin .0 days ofconlplelionof
13h.Uisinfettion type; Amount: well construgion to the county henlih department of the ccumtv.Wlictc
constructed.
Font GWr-1 Nonb Carobirt D,-p itnttmt of Envirowncut aced ventral Resources-•Divislon of W'aler Rmotrees Revised Augtm.'2o 13