GW1--04064_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For trtcraalUsa:ONLY:
The form can be used for single ar multiple wells
1.Well Contractor Information:
la.WATER ZONES
Brian Ewing PROM to D S('RIPIN)N
Wc11(Mote of N.inw' n. n.
4240-B n. ft.
NC Well Connector Certification Neuter IS,OUTER CASING(Tor meNi-card wells)OR UNtR(1f apaieabte)
ono' TO DIAMETER TIOURNTSS MSTT*IN
SAEDACCO n. n. i■.
Compcul Name lb.INNER CASING OR WRING tjr+ttermal dneda.nr)
)RO.1 a TO r DIAMETER IIIR k•ENS MATERIAL
2.Wall Construction Permit#: 0 It. 4 ft. 2 r- SCB-40 PVC
Lu u11 app8i-abfe well promos ii_e.County.Saw,Variance.IitKbl er. ,
ft. n. ia.
3.Well Cie(check well use': 17.WRIER
Water Supply Well: ►ROM TO /VIMITER SLOT SUP 1111001116 MATERIAL
❑Agncultural OMunmipal:l ublic 4 14 ft 2 .010 SCH-40 PVC
OGeothenrlllHealingrcooling'supply) OResidcitial Water Stlpply(single) n R m
❑hdustriabComntetcial °Residential Water Supply.t Aired I la W
SLO
IrRO ' TO MATERIAL EMPLACEMENT ME`11100 a AMOUNT
❑Imgation 0 ft. 1 ft. PORTLAND POURED
Non-Water Supph Welt: ,
n. ft.
XMonitonne ❑Rocosers - _-.
lajection Well: it n.
Li Aquifer Recharge CDGmundwalcr Rcntcduui,'n iv.SgN0:(.FLAX La I'A('I fWapificsMe)
°Aquifer Stontgc and Rttover, ❑S,�linrn Harrier rRniM to M"*aeon ISIPL t r�rNr MrTR(in
2 ft. 14 ft, FILTER SAND # 2
°Aquifer Test ❑Smnm':tcr Drainage
ft. ft.
❑Equnmcntal Technolog °Subsidence Control
2d DRII.UNG LOG lattice additional dices d accesses i
❑Geothennal(Cloned Loop) ❑Tracer MOM TO Di.SCRI►TION rt.ir.hardneg.,was..►npr.gr..wt.,ra I
OGeothennal(Heating./Cooling Retumi °Other(explain under#21 Remarks) 0 IL 5 ft. FILL SILT AND SAND
5 It 10 ft. WET SANDY SILT
4.Date%Ails)Completed: 6-3-24 Well ffteECIT-OA-1MW05 10 ft. 14 ft WET SILTY SAND
Sa.Well Location: R. n.
USCG PFAS Site Inspection R. II. • i Low LA I—•
Faction&loner Name Factlm Ind tit-applicable) n.
e I
1664 Weekiville Rd , Elizabeth City, NC, 27909 R. 11.1 -
Pin steal Address Cin.and Zip r 21.REMARKS
Pasquolank BENTONITE SEAL 1 TO 2'
Count) 1`.ucei hk:atdcat in"No INN h
ih.Latitude and longitude in degrces/mitmtesisceends or decimal degrees: ...(-mirk„ion:
tit well field,one below is sufficient)
N la Brian Ewing 6/21/2024
Signunec of C'cnificd Well LOunraaor pale
6.is tare)the walls): 2(IPennanent nr ❑Tempoiran
UT signing Air form 1 hereby cerriir that the wrfNsr wars(*met anarrraered rn accordance
%IA 154 NCAC O2C.0100 or 154 NCAC n.0.0200 Nell Conrrnrt'riaw Swmdards and Aar,,
7.Is this a repair to as existing A cR: DI CS or K No ,..'n nt du,nrnnf ha,fw•.n prai•4..4 to:he,,all owner.
If this It a repair,fill ant known w tit,trn,NM rum tnfornwr„vi rood ripkan the narrate.'I OR
rrp.rir leader,121 rrnv,rk.,.rn lion or ivr the hawk of Mi.,form. 23.Site diagram or additional well details:
You ma, use the buck of this page to prooide additional well sue details or well
II.Number of wells cnmtructed: 1 construction details. You ma,also attack addih1otral pages if necessan.
for malnple in/rerhv. •rust-s'au,suppl,wells ONLY.:h rho tease awu nwaon van uao
robmir one harm. SUBMITTAL INSTUCTIONS
9.Total well depth below lard surfaces 14 (n,) 24a. For All Walls: Submit this form within In das's of completion of well
For'nalrlplr wells list all ilrpr*I ifdtjferenr triumph,1M 201'and li11Y) construction to the folln sing
10.Static water kid below top of coal. (ft.) Division of Water Resources,Information Prticessing l nit.
/f wear,kohl (dn.iv,&Shag Mu .' 1617 Mail Service Cuter.Raleigh.NC 27699-1617
II.Borehole diameter:8.25" (in.) 24b.for Inieetion W'el)ONLY: In addition to sending the form to the address in
24aabove. also.: submit a cop., of this fono within to dais of completion of hell
11.Well construction method:BORED construction to the follow trig
h .iacr.ratan.cable.direct push.etc t
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen ice Center.Raleigh.NC 1 7699-1 636
tie.For Water supply &Injection Vieth:
I3a.Yield 11:)mi) Method of test: _ .,
— Also submit one cope of this limn w ilhm In dais of completion of
136.Disinfection ripe: Amount: well constnictton to the count', heahh deportment of the carats where
constructed
Fenn GW-1 \,'n li I,n,to ou Dcpannrm of Em riorurta aid Natural Resources-Demon of Water Rootrom R.i isrd Atgtnt 261;