GW1-2022-10410_Well Construction - GW1_20221116

WELL CONSTRUCTION RECORD Farlr�.n�lux���ii^.
Ws form can W used f Wsinglcar nmltip)c tivells;
L'�ti'ciCCt,ntr tciur Itrtormation:
4.WATER 20NES
Brian Ewing FROM. TO. DF'S('R€PTr()
NVO CorAnc or Namo fr. rt.
ft. fc,
4240-B
NC-Well Contractor CeriificationXnu cr IS;OUTER CA;SNGtfniinuhi;imJWcnATO LIIIER(tT!! &abk)
•FROM. TO DL1.�€ETER•. .TFIIC6NE:C'i.. -I aIATERT"m
SAEDACCO Inc it.. f1 .
C0114an)•.N211R; Iti.INNER CASING OR TUBING i'¢athe:rmal clused4wol
FROM TO DWA ETER I TBICGNRSS NSATCRLALL
2,well ConatructirinPerniit 3 TOC(t. 15 ft, 2" SCH-40 PVC
I�rJ'aliappilirallrvr!1 permiti fir.C'aunfv;,alo,11admrcr.11yardag err.:)
ft. ft.
3.Wcli Use(cheel:ivcil else): 17:SCREEN
Water Supply Well:, FROM TO 11TAMF,TER 5110TS97Z THTCKNfSS' I MATRRTAT;
C1Agritu.Iniral 15 ft. 25 fl, a" in. .010 SCH-46 l PVC
®Gcotherrital(Headng/Cooliog Supply) ®Residential Water Supply(single) ft. ft.
01ndustrial/Conwtcrciai 0I1tsidcntial«rater Suppl'.(slued) FROMGROUTTo. 11ATSRrAL- EN[PLACE4€L31T 71!£ffIQD S A Vt8T7 VT
�1rii`atinr 'rt.' fL
Noll-Water Supply Well: ft. rt.
01tunitodrig MccoNrty
Injection well: a, fL
01 qt ifcr Rcchirgd 176orind itcr Rcntcdiatien 19.SANDlGH,%VEL PACK rU a e rlkaDtc)
'F'Re1N1+ft, 2
tjriifcr Storlgbatsd lt£C6CdT}' I�Salinity Bariiiit13 fi. FILTER SAND # 2
❑�44miCrTcst 13�form Rtcebinijnk
❑)ticipt:nmcntpl Ttchnottrgy 0$11h5idcncc Coniml
20•DRILLING LOG(arlach additional sheds if rrecessan-)
OGeotitenrsal.(121medLoop) i7Tncer .FRONT T(1 DFSCRtb'TTO\r[»br,h�rdne.ap4ntc tr n. asicl
oG othennal(Heafing-Cooling Return) 130dier(explain under 921 Retuatts) a ft. 15 R, FILL SAND/SILT MOIST TO WET
15 ft., 25 1L MOIST TO WET SILT/ CLAY
.4.Date Well(s)C6ugrleted.: 9-27-22 Well ID#A4TW-S-02
fi.
5R.1lridl Lricatinue ft. ft. €
Seymour Johnson AFB ft. fL 1�
Facility'+'GtvrcrNumc Faclht.ID,:(irapplkablc) (t, ft. N—�-
1050 Wright Brothers Ave., Goldsboro, NC, 27534 (t, fl. `
Ifhtif�iie�st;,:l �i'i~;;..?wti^vH*t�I_lllii
PIkvikat Aiidtass,eity.,and Zip' "21.Rr M1IARFCS. ..f V
Wayne BENTONITE 11-131
�teteuld Nrcc]IJ:n1inC;tliun No..(PIN)
x atitirdc'atid 11,n"4 tirile or ttccitnat dctm: 22.Certification:
(ifiv�tt t`�Itl�titee I;ti.7di�iS sed't"icRrd)
rw g.
Br! r Ew nr 10/4/2022
�.,._.
Sigmtnrc of Ccnificd W:cll Ca ntrrctdr Date
6.b(are)the{N'ell(3): ElPennancnt or SlTemporay. By signvrb ll;ir farm,1 hrrrLp rrrlif�•fliaf.fiu n•rli(.rJ y;-rrr{i:rn:J carzxrnri7erl i"uccorrluncr
x'irh IS.I NCitC 02G,OIrXi oi•IS.L NCrt�O�C,.9:OD N�11 Gorrarn+crioir Stu+adarticrnairl rle�ia
7.h'this a repairtn an q.ihtin­vell: Ell es .or ®No prrrirkd r�:lr."Sirlt Omer.
rj ri'�t rlx rz re1�Tlr,tid(ravr+`rc+uw TSY•!'F e�xutnrclt'aaa Ltfarratrrr'zm+Trail cilalal�r rJ!€`+urrarrc ref tAa
"ParrtvrirlcrlTal rrrarwrt:s n�.•arma nr-ran rliu b`ru',�of tires fnrue .23.Site diriaam oradditional well aetaits:
You may.use Ure back of this Nge,iG'pldii6 addifi6nil*ell site aetails;or tiVe,ll
R.Number of hells eottstratted: 1 construction details: You rttag also'aiiaclt adtl;linimlpagts if itecoss pry.
hr,midd*r h;&xrl awl tvnrn't_curer J3W-A7'!ril15 ONLY Trirh rhe.samacvrarsrriridm,yNe.nw
ssetwiarmvr :ern. -SUBMITTAL INSTUCTTONS
9.Tui�dw'elt depth below land svrtac►. 25 {ft;) 24a Nor All Wells: Subedit this fn"rrri-within 36 days of'.coinptctiou'of ivell
ForanarNPIC iveff's iar+[IicRprl s f/rf iveart(antra"r{Pe:,t@e a t),,(re,vi 8@1'P97 cOn5tnrctiurr to 4W fojtouing;.
10.Static water level below top.of casiug: (ft.) t)ivision of Water Resou aces;Inf wniatiair Prncesi ing Unit,
}Itr�raer level!,el,avi eosin;;,ass"+" 1617 NlA Sc'Mice Center,kilo ch,NC 27699-1G17-
11,Bnreho[c diamctci;8 25" (in.) 24b.Fnr fniccfinrt Wellc ONLY: in addition to sending dw fora to the address in
246 kore..also'submit a.copy of'titis form ►N'itlihi 30 day;s of completion of hell
12,lire!!WIIStntetidn method: BORED cotrstnicliWt to tlw Soll&%ving:
211P,.rotary.cable:diieci rusk etc.)
'Division of Water Resources,Underground Grji ttion Control Progr•ill
FOR WATER SUPPLY WELLS ONLY: 1636 AL►il Service Center,Raleigh,ETC 27699-1634
13.4l icid(gtitnj llctlind of test 23c.For Water Supply.Yc Injection Wcft
-Also submit one copy of.this fonfi,within 30 days ofconlplet ion of
13h.Disinfectian,tyyper Amount: %veil consiniction-tie the county health department of the coirwWhere,
consinicicd,
Farm GSV-1 North Carolina Depannrrnt of Em'iroruneni•3trd;iaund Resources-Division of Waler Rec r m Revised August 3