GW1--03308_Well Construction - GW1_20230512

WELL CONSTRUCTION RECORD Far R2cnml use ONLY:
This form can be used for sioglc or multiple nclls
1.Well Contractor Information:
:I.L►VAT'ER ZON M
Scott Hunt, Jr FROM To I)MCHIP"ON
WollConingorNaaw 0 ft, 30 ft. water and sand
4561-A ft. fL
I
NC Wcil CowactorCcnifmtion Nt nbr r 3 5.OUTER CASi;<7G(f6e-mu11t;cikd-*d15i OWL1NER(if a" [Ie�bk
FROAi To DF,l1t6F,TER THICKNESS MA WAL
SAEDACCO-Inc 0 ft. 1 25 ft, 2" io;. SCH-40 . PVC
Cengrur?Nanw t6:INNER I':ASiNG OR TUBING` ukermat ciased toe'
FROM 170 1 11MMETER I THICKNESS MATERIAL
2.W01 Construction Permit R: R. ff. a►
List Rll alpilirabfc tact!penisits fir.Coan(y,Stare,Varfarrcr,IryreCD'rsl oi,-.)
3.Wcll Use(cbccic well uscl: 17.SCREEN
Water Supliky WL9L• - FROM I TO I DrAAtr.TFH I sr,oTSr7x Tintxatss I MATF.RIAi,
ClAgiicultutal nNfunicipaliNblic 25 fi. 30 R. 2" in. 1 010 SCH-4o PVC
Meothemtal(Heatitt&Uooliog Supply} ®Residential Water Supply(single) ft. (L
®lndustrial/Conmiercial OResidcntial Water Supply(shared) ta:GROUT
FROM To MATERIAL EMPLACENMNT MEHIOD&AAfOnNT
❑tell ation 0 ft. 22 it. Portland Tremie
Non-Water Supply Well:
Oklonitoring I]Rccovcry ft. nit.
Injecllott Well: ra R.
❑Aquifer RCchaIgd t7Groundisulcr Rcrucdiation M SAND1GRAVEL TACK(if a r i1F:abre)'
'VRONI To I KNIPLACF:HENTHtTHon
DAguifcr Storagc and Recovery DSalinity Qartiet 24 ft, 31 ft. Filter Sand #2
13 Aquifer Test 13S1onnwater Dmiraago
❑Rgierimcnial Technology ASithsi&ncc Central R. ft.
20:DRILI,ilrG'1:OGiattach additionatsbM9if ncccssarvl
DGeodtemial(ClosedLoop) DTracer FROM TO DUCIUMONtcobr,liardtiw wirmckt .grAito Sri!.ctm
DGevflienual(HeafinglCooliug Return) DOtleer(Main under 921 Remarks-) 0 ft 30 ft, s and,
nit. _ ft.
4.Date Well(s)Completed: 4-6-23 WL411D#12MW-22R
ft, ft. .-a, ... •-•
Sa,Well Locathin: ft ft ✓
USCG Base - Elizabeth City ft rL MAY O
FacilitpOwperNamc Facility ll)k(if4plicablc) R. ft,
1664 Weeksville Rd. , Elizabeth City, NC, .27909. ft. It.
Plq,jkzl Address.City.and Zip =.21.REMARKS
Pasquotank Bentonite_seal from 22-24'
(bauty Pamel Midiricllion No.(PIN)
ib.i.*itude and I.ong(tudc in degreWminutes/seconds aI•decimal degrees: 22.CerWicatioru
(ifitcll Sold,ove lablong is hnfflckw)
N W 4/21/2023
Siga7tun:ofCcrtirrcd Nell Con ar Daie
6.Ls(are)the wells): MPetwrmeat OC DTCml1011lCy &signing Mir form.1 hereby eeitije rliar Aw irell(s)lave(%rrv)canttnrcfed ur weardunce
with 15A NCAC 02C,0100 or 15A iVC,1 C 02C,0I00 4'ell Constrecrtan Standards and dare a
7.Is thin a repair to an erdsttingwell: 17Ycr• or ®No ampy bfrliir rtrrorl hasNcm pror4&d rnthn uell turner.
!/rhls k a repair.fill air l-roivn iveil coarrrucrfan hrforemrloit and expiala r1w narare of fhe
repair under d71 rernarks arciian or air the bark of this fornL 23.Site diagram or additional well details:
You tray use the back of this page to provide addifional%veil site detai4 or well
8.Number of wells constmi:ted: 1 consituction details. You uray also'auach additional pages'if necessary.
For mnlriple lnjecrion or ammotirer supply ivellt ONLY idth rhv sgrtle rarrStluctlorr,}you can
submit one form. SUBMITTAL iNST T .TI®NC '
0.Total well depth below land surface:. 30 (R,) 24a. For All Wells: Suhinil ids fort within 30 days of completion of well
For mtiklple irvfls list all depths 1f doernu&xtnnpic-3 ei_f10'aiu12@ 109 y constnietion to I1tc following:
10.Static water level below(up of casing: 1 ((t,) Division of Water R6uu rces,Iafi)rmaruou Processing Unit,
lfnnler level is above casfng'am"+» 1617 Mail Service Center,RA- cigb,NC 27699-1617
11.Borehole diameter.6" (in.) 24b.Fnr Lea FiStieu-Weth ONLY: in addition to sending ti►e forut to the address in
24a above.also submit a copy of this forth within 30 days of completion of well
12.Well construction method:Mud Rotary cottsimction to the folloivine:
(i.e.auger.rotary,cabin direct p4slt etc.)
Division of Water Resources,Underground Injecdon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 NMI.Service Center,Ralcigh,N.C 27690-1636
134%Yield(gpm) hTctirod Of test: 24c.For Water.Suppil&injection Welts:
Also submit one copy of this forntIwithin 30 days ofcompletion of
13h.Disinfection typo Amount: well constnietion to the county health deparimcrit of the county whern
constructed
Fano GlV-t North Carolina flcpmtntcm of Eavironnictn and Natural Resources-limsion of water Resou Revised Atgust M13