GW1--03305_Well Construction - GW1_20230512

WELL CONSTRUCTION RECORD For tmcrttal Use ONLY:
This form can be used for single or multilil:wclis'
i
1.Well Contractor Information:
14EAYATER ZONES'
Scott Hunt, Jr FROM TO DFICRIPTION
Well CorltraciotNartc o R. 27 R, sand and water
4561-A It. IL
NC Well Comlaclor Carlifnaatian Nttrrller IS:0[C[ER CA SING(foru[li eaIH itictls'OR LINER
FRONT Ttl DTAbrETER THIC6r ag hrATERTAL
SAEDACCO Inc 0 (L 22 (L 2" Iu, I SCH-40 PVC
Cerl,^V;ur)•Namo MINNER.CASING Ok� BING poibernW ciased4ou , .
FRONT TO DO METER I THICKNESS I MATERIAL
2.Well Constl•uctiou pellult#; R. It: n�
Liu a!l r.J�yr1i[Trhlr.rrerl l/CnirirE(ix.County,Sta:e.:Yariarrcr,117}rgDCQj rsr_J
-
3.W R'Usc(cheelmd.1 as91, t7 SCRXEN
--
Wnter Supply Well: _- --- --- -.-- __-- -. FROM TO THANt6TPR SrATS67T. TI f(7tNM6; I NTATPRTM.
OAgdcultund Cl1L9unicipaVPublic 22 R. 27 R. 2" in 010 SCH-40 PVC
Meorhann l(tleaUnglCooting Supply) t]Residential Water Supply(single) ft.
EJ1udustriWCoRmtcrcial ©Residential AViter Supply(shared) 16;GROUT
FRONT To -MATMAL EMPLACEMENT MOTIOD&ASIO[NT
❑Irri0tiall 0 ft. 19 (t: Portland Tremie
Non:Water Supply Well:
IlOfv9dnitoring C]R�orxr} R. ft.
I"Jecilon Well: rr, ri
QA[(ttifcrRcctrtiTge l]GroundmircrRcowdiation r9 SANDlG%tVEL ,ACKYif t lj'=M0
-FRONT TO MTT;FtrAL RNIPIA(T.M.NTMI:r110n
AAquifcrStoragc and Rccovery Milinityl3aitict. 21 R. 28 R.' Filter Sand #2
❑AiluituTcst O5tornnatcr lmtilag
❑8=, rin cpml Tochnol'ogy g51thsidckc C014TOt 20 DR1LL111 G'I oG faltach ndriltionatsltcclsit nccessan)
OGeorlteTnal(ClusedLoop) OTracer FRONT TO DFSCR1rTlaf\(cobr.has+rneaw,R'nrckl nFuede.T
t]Geodier al(Ileaiing1CaolWPRetum}. . '00dier(explaiuuiider#IlReivat6s) o tL 27 rL sand
(L f6
4.DateWCU(S)Cmpleted: 4-10-23 CLIIID(t12MW-11R rL (L
54,Well IAMMIII: (L ft.
USCG Base. Elizabeth City (L rL v
Faeilit),Otvocr Nance Ficilk-ID#tif4plimble) ►str
ft. It,
7
1664 Weekspille Rd.. Elizabeth.City, NC, 27909 rL ft u+ • ' t �1;;
Physical Address;.,City,and Zip =21.REMARKS
Pasquotank Bentonite seal from 19-211
Caput} Panel Ide+iIM Mon Na;(PIM)
56.i atitudt and i png[tade in degriceslminutcsJscconds or decimal dcglvm 22.Certification:
(Ifuelt field,ate-I.'Mong it siel1160111)
N W '�"" �'"� 4/21/2023
3igmiLtm ofcei[ifipd Well Con . toy Date
6.IS(are)the.R'ell(s): M- Terittanent or. .ETempora.ry MT•.signfng IN farm.1lrereLl•rerrifv filar the lrrllfs•)xYrs.(scen!)nenarmered in tweortJmire
with 15A NCW 02C.0[0)or 15A+VCAC 021C.0200 MIT Cons[r edarr Sraruta?ds and iMf<T
7.&tkisaxcliahrtoan existing well.- a]Vcs or MNo ccyir_nlrhisrrcnrr)hnshvenpmrirbrlrgdfia�rcllinrnrc
i'/Ihts'ISO fire owrrne of r1le
Trpair udder 621 reniarki•.irerfan ar on the Lurk ajtidr farm. 23.Site diagram or additional well det.1iC4:
You'may use Ube back of this page to proxide Additionat'tcell site details or well
8.Number.of wells capstmeted: 1 CottsliuctiOn details. You may also attach additional pages if nei:essary.
For rard#pMftdevdodt or mvi-ti^nrer srppJr a'rils,O,VLY.n4rh rife same cerrstrucrdon,yore can
su&�nitoicc jnnn. SUBMMAL INSTUCTI ONS
9.Total well del►th betrnf land surface: 27 (('t,) 24a. For all Wells: Suhrnit dtis form within 30 days of completion of well
Fornwhiple wells 16rat1deprhs 2@1M)" consinictipnto live fgltoaiRg:
10.Static water•level below top of casing. 1 (ft.) Div iKiun of Water Rcs• urces.information Erveessing Unit,
if tvdrdr level is i helve aaShrg,MA."+" 1617 Mail Seel ice Ccafer,1L•1lcigh,NC 27699-1617
II,Horchpte diamctcr;6" (ia) 24b.Ur iillindea MMONLY;' lit addition rG.sending the fora to the.address in
24A abom'e.also submit a copy of,INS form within 30'days of Completion of welt
12.Well constritetion method Mud Rotary coustructloo to the following
(i.c.augcr..ratury,sable direct ptrslEc[c:) Division of Water Resources,Underground IaJectlau Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mull Service Conifer,Raleigh,NC 27699.1636
13a Yield(gl►m) 7wlctlrod of test-
Also For.Water Supply&in_icetfnn`Vclfs:
Also Submit one cop), of this fointlwithin 30 days ofcoulpletionof
13b.Disinfection type: Amount: ;yell construction to the county licnhh department of the counts where
constructed.
Fenn GWA Nonh Carolina fAparimctn of Emironn►:1a and Natural Resources-Division of WalcrRMoLlon Revised Atgust 211t:1