GW1--02437_Well Construction - GW1_20240422

1VE;LL CONSTRUCTION RECORD For ituenm!Use ONLY: I
This form can be used far single or tnultiplc wells
1.Well Contractor Informatietc ,
ti.WATER ZONES
Brian Ewing FROM TO D6_:HIPtir0N
Well Contractor 1`anie ft, fL
4240-B It. ft.
NC Weil Conlmclar Cal iftcation Walther :LS.MITER CASING ffor-mufti-civet wctlsi OR LINER ID off livable).
Friom 1 To DIAMETER. THICKNESS MATERi'AL
SAEDACCO IL Ill. iu.
Con4ratry None 16.INNER CASING OR TUBING Igeotheranal clascd.1 i ,,
FROM TO DIAMETER. _THICKNESS MATERLtL
2,Well Construction Permit#: 0 ft. 8 ft. 1" in- SCH-40 PVC
LW aly,lirahlc urnpenrOs(Le.County.,£'a'.Varforrr,Iry'er0'Lat oar.)
ft. ft, in,
3.Welt Use(check well use): a7.SCREEN
Water Supply Well: - 1 Fuual (1 TO DtAstkT};R sun sin I Tin CKNti5 I MATERIAL.
LJAgricultutal UhiunicipaliPublic 8 ft. ! 18 R. 1" in .010 SCH-90 PVC
©Geothennal(HcatingiCooling Supply) ©Residential Water Supply(single) f1. I!!I ft. in, I
©lndustriaUContuacteial °Residential Water Supply(shared) .1&GROf
FROM TO MATERIAL EMPLACEMENT\IE HOD&AMOUNT
❑M:Cation ft. IL
Non-Water Supply Well:
ft, rt.
t1111MonitOring °Recovery
Injection Well: rl. ft.
0Aquifcr Recharge OCroundwatcr Rcntediation 1s.SAND/GRAVEL PACK.Of applicable)
' Fltt►M TO 51L'rERLt1, tOIPI.ACEAIENTMt:Toon
EAquifcr-Storage and Recovery °Salinity Barrier 16 ft. 18 ft. FILTER SAND # 2 •
❑Aquifer Test ❑StormwatcrDrainage 9 ft. ft.
OtiNv;tintcntll TeeltrI010gY °5ubsir[cntc Control 1 2n.DRILLING LOG(attach additional if rtecessarvI
aGeorhiennal(Closed Loop) °Tracer FROM TO . DESCRIPTION(tour0arJnca4.+eetIInKk11 pr.,"•raineve.ea)
DG otltennal(Heatiul/Cooliue Return) []Other(explain under#21 Retuad;s) 0 ft. 5 ft, FILL SILT AND SAND
5 ft. 10 ft. SILTY SAND
-I.Date Wells)Completed: 3-28-24 Well iDosTMW-g 10 fa, 18 iL SILT CLAY MOIST TO WET
50.Well Location: a "]
rt. fL is id.-'t:. 'L.:L 4 •IL,
Former Edgecombe Genco Plant 1tt, rt, P
Fasilit}',Ditner isin Facilit}'1D:(ifappliablc) R ft. ARR 292-2M
6358 Battleboro Rd., Battleboro, NC 27809 , Edgecombe 1 rt, ft. kPr`a „-: r�,'^•;.^>e..,,l't)it?
County, NC, 27809 Physical Address.City,and Zip r' 'L0 •
BENTONITE SEAL 4 TO 6'
Comity Parce]1ttntine;lli4n No,(PIN)
Sh.Lntitirde and Dingilule in dcgrccslminutcstscconds or dccimail degrees: 22.Certification:
(Iforll Hard,one Iai,Iorrg is grdnciced)
N W B1i1a, Ewing. 4/3/2024
Signature ofCeniliied Well Contractor Dale
6.IS(are)the[veils): L]Pennarrcnt or xlTcmltorary -NV signing this form,i lrerebr erne,:Mai rnr roll(sl wax jt:rn)usssinwwred It asonlrmcr
With 15A NCAC 02C.0100 or 15A NCAC 172 C.0200 Well Consrrv,ctiaar Skimiords and rhea a
7.bs this a repair toanccistingwell: ElYcs or l2No repvof ibis ward has ken provided ro;Pe nullmown
l(ahls is q repair.fill aan ktroir+4 well corurnrcalara information and espiahl rho torture of dr.-
repair under 021 irn urLs sr aide or al the hark odds form. 23.Site diaprani or additional well details:
You may use the back of lids page to provide additional well site details or well
8.Number of wells constructed: 1 Construction derails. You may also attach additional pages if uecessaty.
Foran:.elrlplc Injection ararm-warer saeppjr calls ONLY with the sertaecoarstrucfion,your can
=Mironc form SUBMITTAL iNSTI_TCTIONS '
9.Total well depth below land surface: 18 (ft.) 21a. Fur All Wells: Submit this fano within 30 days of completion of well
Formahlplcmeltslistalldrpinifdijei•rrnl(estarnpfr-3€200'and2@1170) eonstntetionto the Cottoning;
1U.Static water level below lop of carsina: (ft.) . Division of Water Resources,Information Processing Unit,
(lower level is above claims;OM"+" [617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:2.25 (in) 24b.For iitJcStirri}Vella ONLY: in addition to sending the Conn to the address in
2-la above. also submit a copy of this fonts wititin 30 days of completion of well
12.Well construction method: DRIVEN _ construction to the following:
(Lerau er.ratan'.cable direct push.etc.)
'Division of Water Resources,Underground Injection-Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
13a Yield(g rn) 24c.For Water Supplhv.tic injection Welts:
p method of test: Also submit one copy of[iris form within 30 days of completion of
13h.Disinfection type: - _ Amount: wet'construction to the county health department of the.county.where
• constructed.
Form 0W-L Noah Carolina Depann;c a of Environment and Natural Resources-Division of Water Rratrces Revised August_H)1:l
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