GW1-2022-04211_Well Construction - GW1_20220419

WELL CONSTRUCTION RECORD for Irtsmal Use ONLY:
lir6 form can be used for single or m altipk wells
1.Well Contractor Information:
fa *11r111TcR:70NI S
Brian Ewing FROM TO Ip�Sf'xgPttt}v
Well CurftolM Nzrmc ft. ft.
fL ft.
4240-B
NC Well Cortnaor Cert:ifmcation Nun bes I&OUTER CiAc1NG et�1t3=ai4cil+tteFls�?it L1t4L7t. lf.a tie56k
eROM I To oTAMETER TMCl NM, MATERIAL
SAEDACCO Inc 0 fL 8 fL 2" in. SCH-40 PVC
( rsnplrry Karat
76 iIV4NF�tCrlSllllOOJC f81NQ lteniattlevedabn ,
PROM To I DFAht MER I THICKNESS I MAi1 RIAL
a,Wd1 Constmetion Permit# f1. ft,
List u1l applicable uiell prnmirs(i-r.Counn•.StNor.Variamrr,Inferdrrt ew.J (;„ f4
3.W[Vse(ChM;well useli': MSCRECK
Water Srggd}•Well: FROM I TO PIAIISQ•rsrt I VOTStZk: I T1113CxN1Z55 I MATRRIA17
OAgrimImral I7lvlt10icfpal1public 8 ft, 18 ft, 2" Im .01 SCH-40 PVC
OGeothenw- 1(HeatingfCooling Supply) ©Resider.ial Water Suppy,(single) n. rt.
❑lDdusniall/Comntcnial OResidentiaf Water Su 1144=011T `.
ppt}'(S_hIlredj MOM TO MATFRIAL EMP1-4CEM WMEfirOD&AMMW
❑ Holm 0 fL 4 fL PORTLAND POURED
Nor-Water Supply Well:
rt. rr;
IR Monitor n o11rxr+�
injection W¢ll: rt. rt
Mquircr Recharge G otinrlaatcr Rcmediotion 49r ANrifGkAVBl.1sAt Ct; ap k2b
FROM MAT>yeerA1. Fslrl.a It"Mr-Nrhlr:Tn sm
f]AAnBfer.Stoiage Atmd RCC9M1m Jt' p5alinin>3arricr 6 ft, 18 ft, FILTER SAND # 2
❑A.*fcr Test 13Stomrrcarcr Dminav:
ft ft.
❑F.VMnlCotal To;hnology, ❑SmdmSiticKc Control
3tkDRI[d3I G WG-sttrtch-adifIflomxl. bmis If tre¢slrAnl,
1343"lhennal(Closed Loop) ❑Tmeer Mold TO Dlrmcnmp>ila� uorar,aardricn�,tluroca r��e+e)
❑Geodiennal(HeafitgCooHn Return) ❑0lher(explain under#21 Remaiks) 0 ft 5 fL FILL SILTY SAND
5 ft 10 ft. MOIST SILTY SAND TO WET
4.Date Weil(s)Completed: 3-29-22 Well ID#MW-12 1
10 ft. 18 ft WET SILTY SAND
Ste.WC11 L ICYtirrn:
Airgas rt. rr �
Facility/Owrrer Ntinx Factlit)-IDS(if appikarble) ED
4108 US-117, Goldsboro, NC, 27530 A. to, APR
Plnsicel Address City.and Zip ;Y,t>IMMAI MSI
Wayne BENTONITE SEAL 4 TO 6' IrAomew
Coumr halcel Idtrdiru=ion No,(M)
Sir.I-atitade and I,ungifide in degmmOmimtteslseccnds or decimal dam: 22.Certificatinn:
(it'vrall field.mic k4lo g is sldFici:nl) p
x w Br :a,n�_Ewing, 4/1/2022
Sisa3tu urGcntGcd 1 Canlmctnr Date
6.Is(are)the well(s): MPermanent or oTemporary 1i}Sigah'o,A,ahis foram,1 hereby eeratifv thrar the mellf sl tour f wrrel ccnarrnnred by acranhmcr
with l5A NCAC 02C Alm or 1SA hrCAC MC,0200 Well Coxsrna-rlon Strarylrirds 417ril Owt a
7.Is this a repair to in esi.Wng well: oyes or MNo mpy of thin m ni has 1won prorirllvl ro ahr ilrll runner,
If Ms Is o relxrlr,fill4avr Axw1 a w4f c onslrwotem htfgmwrkm and rxplallr the nrue+rc Pf Me
repair antler021 reroarkr.Tn*n or ran the hruk of ibis form. 23.Site dfWsm or additiotiaE well details:
You Reap use die back of this po8e to pmxide additional aril site d tails or well
8.Number of wells cotuintrted: 1 construction details. You map alfla afiach additional pages if necessary.
For moMple PtWrkrr a Arai-uvrer uM%1r hells ONLY tdrh the mme construction,3,4v etra der xT
.Ma`Ulif one foRA. SUB&ir 1 1 ALL I S 1 UCT ONS
9.Total well depth beloif land surface 18 (R,) 26L For All Well sa Submit tlds form within 30 days of completion of well
Formantlplawrtlsllsraticdrprhr1fr111ir'rena(exnipte-3@2t10'anti?@IM) con5innctiontothe bilpniog;
10.Static}hater level below top of casing (f1) 6ir6ion of t6171Ma Matt
Water
Resources,Information Processing Unit,
lfnnrer level&above c•aslap,arc•'+' Ser 'ec Center,Raleigh,NC 27699-1617
11.Rorrbok diameter 8.25^ (in.) 2Jb-Fnr lubmiJrrn Wetta ONLY: in addition to sending the forgo to the addles in
24a above. also submit a copy of this fomi witllin 30 dM-s of Completion of well
1.2.Well corrstrur-tion aretbod; BORED construction to the following:
(i.e.auger.rotor)'.cable.dimes paslc cte.)
Dlt•Ision of Water Resourccs,Underground Injection Control Program,
FOR WATER SP,PPLY WELL5ONLY: 1636 Mail Sery ice Center.Raleigh,NC 2U"-1636
lJ&Vidd(gprn) McBmod of test: 24c.For Water Suppy&inlr:c,Ch n Wells:
Also submit one copy of this forth Ivithin 34) days of Completion of
13b.Disinfoction type: Amount: mmll eonstnmction to the comity health depart mart of the coauft wix-e
constructed.
Form GW-t Nonli Can 1mi DMamRent of Ezwiroaurrraand Man"Resources-Division of%Voter Resou`r M Rcyiscd August 20l3