GW1--02433_Well Construction - GW1_20240422

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WELL CONSTRUCTION RECORD . . . .. •
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TJin form an IN used far:Single Or multi*wells'., • . I . •
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1.Well Contractor Information
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. . . 14.AVATIZR ZONES
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Brian,Ewing . . . FROM ' TO - - "DFSCRIPTION
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• Wen Cpuiractoi Nam, . - . • ' ` . ft.. rt.‘ • t '1 . . .
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.ft.- ff. . 1 .1 ' . • • . . • . .
42 40-B: . . .
• NeWell COulreefor Certilicatioil Nuttier' 1 -'. • ASOUTER CASING fforinuIlkasettii-dIsiOR-LINERItfli#Ileable)'. - r •
. • -FROM -TO ' ' n14,11ETPR•I rttrKNEss, • IITATERTAL •
SAEDACCO . . . . •. .fL - ff.. - ! IU.
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. Company N:use , ' : ' , .16.INNER'CASING OR TUBING(ieothennil elosed4oap) •
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• . . --FioNt •'Tio DIAMETER. 1111CKNESS IV IATERIAL .
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0 . .IL 13-• ft. 1" . . "in. scB-40 PVC
2.Weil Construction perinit 4: . . .
List ail likre valtpenvits,(Eq.County.&roc.Vaelarrre.friedeft etc:).
•ft: ' ft.- * • .* , .
3,Welt.Use(checicit'elllisA1 ' . ' • E7,'SCREEN
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' Wafer Soppily Wtql: .-- - - -'• . . . . MOM. TO • .•DtAritETtit sun-sirs: TtiteRNISS. I MATERIAL • . .
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- • • 13 ft 23 •fl. 1 11.• :.010 SC.H-4 0 PVC
DAgrieultuml, CiMmieimiliPublic .L. R.
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fc. ia.
13GeodieOnal(bleatingitdoling Supply) • CiResidential Water Supply(single) ' IL
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CI IndostrialIConuticreia I . . , EIResidential Writer Supply(shared)
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.• ' - ' ' • • . 38'1GN RT°•fItr,•'r T.O
.M_I.TERLI.L- - EMPLACEMMT M.-E.THO-,
D&AM-OUN T
Ekiipation. • • FRO'
NOR-Watpe Supply N11
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BlIdonitoting'. ' - . . ' , .1:112ccoyety• . . . . .
Injection Welt:- - . - .- ...ft.. . . rt. . • . . •'
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E3 Ai-pilfer Recharge' ' - • DOiountinincr Reicdiatitin• -,LI:SAND/GRAVEL.PACK Id appticable)••
''' " - • ' 'PROM- '' TO' MATRRU I;',.• - EMPIACtatiNT so:Toon -
PArptiferStoragc and Recovety ' ' 1:1$iiiipity 13iiitio'. •
• 3.1 • ft. 23 ft. FILTER,SAND # 2 • . .
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CI AgOifor.Test • • ElStormwatcr DratOoge - '
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. 1:15Sperimcntal Tcchnolog ' • 0Subsiderwe Ciattrol . • •' - . . ., . . - - -- - .
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• -. . •20.DRILLING LOG•tuttietr additional sluxti-ir necessary) • .. . .
Lltreothennal(Closed Loop) . - bTracer. FROM• TO - ' DESCRIPTION Rotor.hanfaca.itniVnitk ttiw.taaid Nide.ttra
EIGeothennal(Heating/Cabling Return) '-1.30ther(explain underkl Rettiaths) ° . 'fr•.. 5 ft, FILL SILT AND SAND .
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. • • ' * 5 'fL 10• : ff. -SILTY SAND . .
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4.path:Wekt(s)ftthipld1cd: 3-28-24 .Well IDA;Tmw-11 . • - - •
'10. .ft.. 23 ri.., SILT CLAY MOIST TO WET• '
Sa„Well Ltication: • . • • . -ft • , - r.:.-.7, :77., -.•- :•, .--- •t• , •
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• Former Edge combe Genco Plant ' . . . --rt, - f), - . . _
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- '.. FacRity/Oivneriisme . •. Facility IIM.(ilapplkable) ft ft
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•. . 6358.Battleboro.Rd., Battleboro;.NC 278 0 9 ;,Edgecoinbe ' .It. . • ft. . . 1.1.?,:r...m..,.i.•:,.......,i... ia.5,-,-.,r,..I.r,,.V.,.--.'.3'•Ji,,•it . : .
. • .County NC; 27809 . - . . PhytidalArMil.,City..ahrl Zip• .,„,I.licatAnics • • • . [IN,,,i•-noN:..,s .
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• USA - , . .BENTONlTE SEAL 9 TO 11'
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. Comity - Patel laegiutlealiou No.(PIN) . .
, ' . ' ' . . -•• Sh.II:atitude arid Longitude in degmcsimittuteitsccands or dechnal degrees . .
22.Certifieation: . . . . . . .
OrWeli limo:sit:aft:1s isSuMeloio) • -..
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N • . - • - • - W Brian: Ewing . . 4/3/2024
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. •. - . • _. : . _-Sigmour,ii'CeitifledWell Contractor : ,-: ... Dale ' . • . ' :
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. . 6.Is(are)the well(S):.ElPermanent. of 11Temporary .
•di signing this farm i hereby certYy that the 1;•41fsl war iKrrej cvnIgnaled LI actorriarncr .
. - with 1511 Arc,,4C 02C WOO or 15A NCAC 02e.0200 wo Construetion Standards and that a • . .
7.Is flits a repair to art.Ciisting Well; . DYes or 12 No .
'co&af Mk wont has iiienprovideti to tin;yell oilmen
. . If tigs'is o itpdr;fill out Amin i HMI constnrctiou Infortnotton and rAplahrthe tiorare of the • . - .
repair rinikr 021 irtnarks:Srcii,in.or WI thi:11 dek Ottill.:V form: • • - . • 23.Site.diagram or additional well jeta0s: ' . •-_ • . .
. . . , YOu may use the hack of this page.to provide additional well site detail's or:well
. - 8.Number-of Wells constructed: 1 • .• .. -- tonsituction detailS. You ittay also attach additional pages if necesSary.
Foiilthltlp.r.e infecilmi or 1:JAP1-`1..oarer signxr,i welfsgmx with the sante construeiton,yon Ain ,, I •
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, SZ011iftIVIE/ORA: SIIDNIETTAL INSTUCTIONS ; . .•
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9.Total well depth bdow land surface: 23- . • *- (fr.) -24a.-Fur ALL Wells:-Submit this•fortn Within 30.days of completion of well- •
. ' Forktiitiple rivet/slit:all depths'ildOinent(example-3€200'tuni.2@ WO) ' • • construction to die following: . .
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. 10.Static water level below tap of easing:: : (ft.) niViNIOU of Water ResaurceS,Information PrucesSing Unit,
. ' If wet;kvel it above mita;ate"+" . - ' • 1817 Mail Scrvice Center,Raleigh;NC 27699L1617 . . . ..
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• 11,Borehole diameter;?r 25 ' 'dm) . - 24b.ForTplectigp Wells ONLY: In addition to sending the form to the address.in•
• - 24daboye.also submit a copy of this form within 30 days of completion of well
• 12.Well cOnstenction Method: DRIVEN • , consIntitioli IO the folloWing: ( ; -
(.c:20ser:rainiy,cable,direct pads.etc.) ' • '
• "DEptsluu of Water Remo reei;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:' . • - . . '• 1636 Mill Senice Center,Raleigh,NC 27699-1636
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. . 21e.-For Water Supply&Injection Weis:
13a.Yield(gpro) - •- Nleiliod'of tot:
• Also-subthit one copy of this Rim Within 30 days of completionof.
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13h.Disinfection type • : Amount: • , -wctl construction to the county health deportment of the.coun .where
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• . Fa imGW- . - • North Caro Itna EptunSent of Erwiroyucru and Nam!Resources-Maidon of Waier Il_cut . • Revised Altai rzt101:1 .
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