GW1--02428_Well Construction - GW1_20240422

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• WELL CONSTRUCTION RECORD . .
Fur tutinial;Ise PN.LY: ' • . 1
This Iona can he used far single er multiple wells•
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1.Well Well Continctor Inforntation: / •.
. . :IL-WATER Z.ONFS- . •.
Brian Ewing , .
, • . 71400 70 '• • -0F,8CRICIION
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Well Contractor.Nam • R. ft.e . . ,
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4240—B .ft.• . It. '1 I. ' -
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NC Well Coraraciataitificatioli Walther. : • ;:td,OUTER CASING(fortaulli-cuscd-WCII5)OR LINER(if-ati)11eRtile)
. . FROM Ttt ' ' DIARBETER ' WHO:NESS I.ATEIIIAL• •,. .
. ,IL ft.• • • In
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SAEDACCO
Cantruty panic . t6:INNER CASING.OR TUBING fgeollterzbal clowd-loop).• ..
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. • FROM TO• ' DIAMETER.. THICKNESS MATERIAL
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2.NVOItontrpition rrtnit#: • . . .,
. 0 "It. 8 ft. 1 • :In: 'SCR-40 'PVC [ "
Uzi 411 applicribk well pennits(ix.antnry:-.Shrte,Afari awe.[lethal ric.)
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3„Wciltiie(chcdc well use):
. • • 17,'SCREEN
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• Water Supply Well: . • • . FRO51. . 10 'DIAMETER SLOT SIZE. THICKNESS MATERIAL
• • - • 8 -;ft. 18 'ft. 1" " •in 010 ' SCR-40 PVC
LIAgrieultural ' .InlyiunidipaliPublic. .
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1Geothetmai(ieatingtooting Supply) °Residential Water Supply(single) IL ill
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CI IndustiialiConuttercial °Residential Water SuPply(shared)
118;:osrT0 ... .... .
• . I.NIATERIAL ' EMPLACEMEN T 11E1110D ANIOUNT
' 0 Itt . .ipation 6. . •
-Non-Water Supply Well; • • .
* ft... , ft„. •
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Monitoring . ". . . . °Recover).- i• . :: •
-ft.
- • .. ItlectiOR'Wgit: -- . .
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Orioptifer Rcebdrge" - ' 6 OGIoundwaict Rcniediation ' • "i.tsr.SAND1GRAVEL,PACR(if applieabM
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• • Elt()NI TO' • 'MATERIAL . ESIPLACENIENT MEtHon
°ArptiferStoirag,e,and Recovety • , I3$alinity 13arrict
• • 6 R. 18 It. FILTER SAND - 4).2
0 Amilfct Test CIStormiratet flntnagc •
ft
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IDEkperIntental'Tiirtoto.m,, I:Subsidence Coniro1 . • . . i.
• • . :14.'DRILLING'LOG(attach additional sheds"If Reccssarvl -•
°Geothermal.(Closed Loop) . ' bTmcer. . ' .• _ . FROM-. . DESCRIPTION(obi..hartIncti,WV nitk Mx.orsika!die.tte.1 • -
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EIGeotheituat(Heating/Cabling Return) °Other(e.xplain under821 Rettiaths) 0 -"ft.1 5 rt. FILL SILT AND SAND .
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. . . 5 -ft. 10 ft, SILTY SAND' '
• . .4.):Iate Weil(s)Completed:.3-'28-24 - .Well Mi:til4W-3 - . . _
• •10 , ft. 18 ft. SILT CLAY MOIST-TO WET - '
5a.Well Ipeatfure. . ' IL it,. • 11-A.-i...;CS....•.1..*:.i lel•i7
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• Former Edgecombe Genco Plant . ' . IL' ft, ,
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Pacilityfflitner:Notte. : .- . . FacOity II),(itapplizable) ft
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. . 6358 Battleboro.Rd., Battleboro;.NC 27809 ;,EdgecoMbe , ft. ft;
County, NC,' 27809 ' Pl6tiaill A.44.F•s,Pt).-344±43. ,-2L.ftEilARIC.S Vi 4 k.,..;::;‘,),....) . •
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. . .BENTONITE SEAL 4 TO 6'. - •. . . . •. . . •. - • • • "
Glumly • • , Pared l Ideulikation No.(PIN)
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• 56.Latitudeatid Longitude in ttegreesitninutegsccOnds or&chill degrees:
• " • ' 22.Certifitation:
(if%sell field,one hufletisktfileleitt)' - •
" . • '- . . N. •. • -.• .. . • • ' - 'NY-.. . Brian Ewing 4/3/--2 024
SigtutureifCeri_edWellCentractor Gate • •
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6.1s(are)the well(s):.OPerinattent .or SiTemporary . .
'Hy.SignArg drix form,-1 hereby certYy that,the Irefh)wan Olvrel cutirtnrcted an accordance
, • trier FM ArCAC,02C.0100 or 15e1 Natc•02 .0200 Well Consinnition Srairdards(ad kat a - . ..
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7,Is tlids a repair to ane.visting well: . IJYLS or 18No • •rooy cicrikrreord ha No4 pr,wide4.kr ibi:urn ruturr. . . .
. If ells'Is a pepsin:fill an ATWilil!weld coaanin'oo laforataaan aid(sahib;the nature of Me
'repair ritrtirP21 iroiarkrtiaiierr an the boa cifthis joint. ' . ' 23.Site diagram or additional well details: ' -! ! • -
'You mg use the back of this page to provide additional well site detail's.or.well
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- • 8.Number of wells constricted: 1- .. , • . , . - . Construction details. You May also atiachadditional pages if neceskty. . .
. . For innitigne infeciloa or oan-laaer s'app(t walk OP.'LY with the setae construbloa.yon enn
submitime fiarra. - SUDiiIITTAL INSTUCTIONS 1: . • •
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' - 9.Total well,depth hetoW land surface' 18 • • ." . (9.) .24a. for All Welk; Submit dos them within 30 days of completion of Welt •
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. • For maIrlitriivells list di dep.&if diiii.fiaa(e,soaiptc-30200*mull@ 100) .' r. construction to the Cottoning: :' . .
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10,Static water level below tap of cosinw • -(ft). . Dividun of Water ResatiiiieS,Information Processing Unit,
iill'illOP kver is above.casfax use"+" -. . . - • • -. 1617 Mail Service toiler,Itale10,.Ne 27699LI617 , • . .
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IL.Bore plc diameter:2.25 '(in.) • - - 24b.Forinicetion Wells ONLY: in addition to sending the form to the address in .
. .24a above,also.submit a copy of this'Twit within 30 days of.completion.of well
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12.Well construction Method: DRIVEN . . . ,. consttuction Co the folloWing: . ': '•
(i.e.auger.rotar).table.direct rink etc.) ' •
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'Division of Water Resources;Underground Injection Control Program '
FOR WATER SUPPLY WELLS ONLY:' " . :• • -1636 Mail Service Center.Raleigh,NC 276994636 - -
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• • Its,for-Water Supply Ai Injection Wells: • ,
- 13o,Yield(gpro) ' . . Method of test: •
Also submit one.coPy•Of dui fOint!Within.3'0,days of completiottof
- 131.DiAnt.otitton typel . ,, . Amount: . _ , . , well Construction to the county health!department of the ecundy.wlicre - ' .
constnicied. t
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Form OW-I • . " • Not*C3R4i1L1 Etfixututent of Rneireitineat sad Natural.Resources—Division of Water ResotrosH --Revised August11113'
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