GW1--04060_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD f 'u Fortwins!Us ONLY
This farm can he used for single orInformation:mullipk,sells `)
°°
I.Well Contractor Information:
14.WAY/R ZONLS
Brian Ewing PROM t0 _ Dr14RlPl ION
Well(',.ninon,N.-ma n. n.
4240-B n. n.
NC Well Cowniclor Ccrification Nnntbct 15.MITER CASING(for muki ells d weld OR LINER(If Ikable)
!ROM ; TO DtyHrTFR TNN'KNiss NAITpI AI
SAEDACCO n. I n. ill.
('ompvan Nava 16.INNER CASING OR TUBING taseaerreal closed-l.w,p)
Rost To DIAMETER TOR 1 01s, MAITRI\n
2.Well Comentetion Permit N: 0 n. 5 It. 2 fill- SCH-40 PVC
List all applicable urn permits tie.County .G.rn,l'..rian..e infection r...! •--
3.Wall Uwe wheel:well user: V.SCREEN
Waler3ttppl. Vs ell: PROM TO DIAMETER jcliot.in nurl:vto i MATFRIAI.
ElAgnctikutal I_IMunicipal,�Public 5 R. 15 n• 2 fill O10 SCH 40 PVC
R. ti. is
OGeothemtal(Heating.Cooling Supply l I!Residential Water Supph(single) �aa�a�
U hd nt ustrialiComercial I!Residential Water Supph'shared)- io _......._._._.__1..N STERIA1. EMPLACEMENT yIE TNOD l.AM(x:NT
Dktigptton 0 n. 1 ft. PORTLAND POURED
Nes-Water Supph Well: R.
JDXIonilonne ❑Rccoscre
Injection Well: a It. I
']AquiferRecharge DCimundw:atcrRemediation ItSANRPG AVILPACE(rampRntkMt)
room TO MATERIAL. PAIN.trrwr\T METRO')
❑Aquifer Storage and Recosen ❑Saline[} Hamer 3 ft. 15 ft. FILTER SAND { 2
❑Aquifer Test ❑Stomws:ncr D ain:tee It. n.
❑Espcdrrental Technology- ❑Subsidcrcc Control
2.DILU'IG LOG( 1.cl additivaal sheets if accessan I
DGi othental iC l used Loup l Ell racer Molt To melon ION..Derr,Manioc...w.rw,w t nisr.r ale..e.M.I
❑ rm Geotheal)HcanntK•oolillg Retool) Dlhlkr Icyplam under#2I Remarks) 0 ft• 5 ft. FILL SILT AND SAND
5 R. 10 ft. WET SANDY SILT
4.Date Well(a)completed: 5-29-24 Well ID.ECIT-NW-1.5W01 10 to. 15 ti WET SILTY SAND i
5a.W ell Location: ft h
USCG PFAS Site Inspection h. N.
i.01:4, (1,,,,,\, Facdtn ID#inapplicable) n. R. iz\ t�`•1 t /E,:5
1664 Weeksville Rd , Elizabeth City, NC, 27909 v
---- n n 11J1 1 2�24
Ptgsecal.Addicss.cirri.and zip 2L REMARKS
Pasquotank ' BENTONITE SEAL 1 TO 3' Q� wr�� ._
lfi ill '
- _ .71i�'.s'
('..unit Panel WNW-A' No !PIN, 'C„d!(.V
Sk.Latitude and Longitude in de((iresiminutes.'sccnnds or decimal degrees: 22.('ertificati n:
Orwell field.as kaloup is ustric,eul l
N W Brian Ewing 6/21/2024
Signature of Cenifxd Well(aalrt.lot Date
6.Is tare)the%elks): RJPerinimeut or temporary
ity signing this horn.l hereby certify that the Heats,sus ftsrrrl constricted m arrondmrtr
with 1 S.(NCAC O2C.0100 or 1 SA NCAC 02C.0200 Well Con:ow:eon Standards and rho,.
7.Is this a repair to an ezitiug well: IA es or 2L No n,y.i nr du,.e,nod has Isvn proraied rn;he.rrll owner.
If this is a'woo.(Ill,.at known well,font,*tom rnJtlrw4tr4Nr and r[plats the nature.'(thy
rrls(ir,aalrt 021 r,m„rA..nr,ir:m or ui the b.rt.,f this fors. 23.Site diagram or additional well details:
You nor, use the buck of this page to pros ide additional well site details or well
S.Number of%ells a isstrr etcd: 1 construction details. You may also attach additional pages if iret:essart.
For.ealtlpk injection or cow-loiter supple wells ONLY with Me weecoestracaion.%,Nu eon
sahreir one form. SUBMITTAL INSTUCTIONS
9.Total wd)depth below lard sorfaee 15 (rye) 11a. Fur All Wells: Submit this form within 31.l days of completion of well
For wralripk hells list all*Ott ifdtffrrrns(r.rmnple-7*.0O and:*loin constructiontothefollowing-
III.Static water Icy el bc•luw toy of miry (rye) Division of Water Resources,Information Processing Unit,
1617 Mail Service('cater,Raleigh,N(-27699-1617
I I.Sardonic diameter.8.25" (is.) 21b.for Injection Yrdjl ONLY: In addition to sending the form to the address in
24a above. also submit a cops of this form within 30 class of completion of well
12.Well construction method:BORED cotnnnutiun to the following.
(i e.auger.roan.cable.direct push.etc.)
Division of Water Resources..Undcrg d Iljec toe Control Program.
FOR WATER SUPPLY WELLS ONL%: 1636 Mail Service('enter.Raleigh.NC 276994636
24e.For Water Solon,. S Injection hells:
13a.lido Igpro) Method of test:
Also subunit one copy of this forth within 10 day s of completion of
131i.Disinfection hod: Amount: well consmm county
cnon to the coty health department of the county where
cortstmcted
Fenn GW-I Nonh Catolitu U.punnrtu of Etn innocent aid Natural Resources-Disarm of Water Resowcm Inc,used August 24,1