GW1--04059_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For Inertial Use ONI,..
The form can be(nod for singk or mobipk hells
I.Well Contractor Information:
II.WAFER ZONES
Brian Ewing n OM to I DONCRIET1ON
Well Contractor Name n. ft.
4240-B
ft. ft.
NC Well Contactor Certification Norther IS.OUTER CASING(for emlO-card sells)OR LINER(U ankeabkl i
IRON TO INAMtTER TAK'ICNTSS MAITnRAI
SAEDACCO h. fl. ia.
Compaq Name 16.INNER CASING OR TUBING ta[tlliermal cine44uwp)
FROM to DIAMETER IHIC'M\Fs5 SI.l1TNIAL
2.Well Counttllrtion Peewit E: 0 ft. 2.5 n. 2 10- SCH-40 PVC
last all applicable wraprnmsi fire.Count Shoe.l lv,Lmr froceort rL. .
n. n. MI.
3.Well I-se tche•I:well oral 17 sperm
Water Supply%tell: PROM TO DIusln:a 11ATs177 1TIKT(NIRtS MATKRIAI.
I IAgtr;ulnual I_IhlRtdcipalrAtblic 2.5 R. 12.5 ft. 2 to. .010 SCH-40 PVC
I'Geothermal(Heating,Cooling Supple) 11Residential Water Supply(single) n ft. is
I IIndustrialiComntereial I IRcsidcnnal Water Supply'tshlredl IE'Git10T
FROM TO MATERIAL. EMPLACEMENT METHOD a AMOUNT
Dhngation 0 ft. 0.5 ft. PORTLAND POURED
Non-Water Supply-Wed: R ft
NMotutnnne °Recosery
1'Rjection Well: n- ft.
°Aquifer Recharge ❑Gmundwatcr Rcmcdiaaion It SAN VEL PACK Of ap.licaYe)
❑Aquifer Storage and Recovery ❑Salirdty Barrier nest To MATERIAL EMPIAtEMtNTMtflgs
1.5 ft. 12.5 ft. FILTER SAND # 2
l7Aquifer Test ❑Slomnsatcr Drainage
ft. ft.
❑Expcnmcwal Tahnologs ❑Substdencc Control
2S DRILLING LOG tails&aMitisesl Ards if ncceinan
❑Geothermal(Closed Loop t ❑Tracer PROM To DPSCRIPT1ON ii»br.haMrw•w,...wool ripe.gab n a,wt.1
DGeothcnnal(Heatna;C'ootiug Return) DOther(explain under 021 Remarks) 0 IL5 n FILL SILT AND SAND
5 R. 10 ft. WET SANDY SILT
4,Date Well(s)Completed: 6-5-24 will Its ECIT-HM-MW03 1
10 ft. 12.5 ft, WET SILTY SAND
Ss.Well Location: R n.
USCG PFAS Site Inspection ft, n
Faction Os Ter NaTr, Facility tD0(ifapplicable) R. h. .4` ,
1664 Weeksville Rd , Elizabeth City, NC, 27909 f ft.
UL1 2 11124
Physical Address.Cin.and Zip it.REMARKS
Pasquotank BENTONITE SEAL 0.5 TO 1.5'j,(, :Z•. a 4- r •
('slow) Pared ldculifs-iiw',No ,PINT DFfL.,i SC,ii
Sh.Latitude and Longitude in degnresfmhmQsheennds or decimal degrees: 22."mirk atwlR:
;i( ,.11 field..m falotg is sufficient)
N „ Brian Ewing 6,21,2024
s,,,L u-s:01 s.co 1 I s:d kc,I l„utcw(ot Daft
6.Is(are)the Nr111A1: X'Permaiwnt or ❑Tlmprar7' 0,.rtarsine tau h,mr,I hcrrhs reel that the wriffrl war fired corirtnNas!or acrordmtcr
wxh I 5,4 NCAC 02C.0100 oe 15A NCAC 02C.0200 Well Consrrw•n'otr Standard,u,wl this:is
7.Ia this a repair to an existing well: Olin or NNo r.T,c of this record ha,hero provided o.the.sell owner.
!f this u a repair,fill OW 610Mb well l•OIRAnIR/M.n,mtlirrwiwelss arid eapla/n the INILare of Mr
repairaader I2!remarks Arctiom or an the bark of this farms. 23.Site diagram or additional wd1 details:
Yon may use the back of this page to provide additional well site details or well
IL Number of swells easstracted: 1 cotrsu fiction details. You tea'also attach additional pages of mammy
Fur malnplr sole,roan.N moo-owe,rwppis wells ONLY with rho soave cotrstrlrcnua L:u,.in
smAvslr one Pon. SUBMITTAL INSTUCTIONS
9.TSalwdl depth below land sorfaee 12.5 (ft) 24a. For AU Wells: Submit this Conn within In days of completion of well
For mahipk Sitilt Inr,ell s)•prhs ifd.f ervo ie.tawgrlr 3102(0.and 26"S 1(571 constntctlon to the following,
111.Static N Ater Icsd below tap of cubic if" Division of Water Resources,Information Processing l nit.
Omar.k.el r,oho,r,awl.ass"4.•• 1617 Mad Service Center,Raleigh,N(•27699-1617
I I.Bards*diamden 8.25" (is.) 24b.For lnkedea Welb ONLY: In addition to sending the form to the address in
Iaaabose. also submit a crop, of this Conn within 10 days of completion of well
12.Well oeawewdNn method:BORED construction to the following.
(i.e.auger.rodan,cable.direct posh etc.l
Dlsisiunfir Water Resources,tlrtdettruund Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I(06 Mail Sew ice(enter.Rakish,N( 21%99-IA3t.
13a Yield IEpm► ltrltthsd.tsest Ile.For Unto Nupph S.Injection Wells:
Also submit one cops of tins lotto niHim IA) class of completion of
13b.Disiafeetian type_ _ Aliment: well construction to the cotton health deportment of the camel)s;here
constructed
Font GW-I Nall Cainluta L)epmnment of Ern IIcIuiciu aid Natural Resources-Dw noon of Water Reams Ho wed August do 1_l