GW1--04076_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD Pot Internal Use ONLY:
The form can be tined kw single or nndnpk wdk
I.Wdl Contractor Information:
14.WA =NIRS
Brian Ewing r*OM TO Dine RIPTION
Wc11 Cottrackm Name R. ft.
4240-B R, rt.
NC Well Contractor C rnificatwm Nanber 15,OUTER CASING(far m.Miemed wens)OR LINER Ill applicable)
rROM ; TO M;MTTFR THK'k'cini N1 0TRlal
SAEDACCO II. i II. in.
(•onou” w W INN'S CASING OR TUBING , rasa clawed-Iwtpl
FROM 01 DIAETER TRI(hnina HtITRI.+I
2.Well Construction Permit N: 0 R. 4 h. 2 r• SCH-40 PVC
Liu all apphr able nrl!}w^nnu,rr r.Carom,Snare.tvrianr !,arson eh.l .M - -
R. fi. in.
3.Well Use(crack well uw•t:
Wafer Supply Well: PRoat Io Dlr,MVTlR a 01 sun 1 11111(1041fifi MATERIAL.
g .010 JSCH-40 PVC
I I A ncuhural OMwRci l:Public 4 R. 14 i1. 2 �• .
11Geothennal(1-em1111/+Cooling Supply) OResidetuial Water Supply(single)
R, it. itr,
I I htdustriat Commercial OResidcir(ral Water Supply(Owed) 18'GS(10'T
FROM TO MATERIAL EMIFACTMENT METHOD/AMOUNT
❑lrngatton 0 R. 1 ft. PORTLAND POURED
Non-Water Suppy.Wed: R. W.
Eklonitonne ❑Recovcty ._•, —1
Injection Well: R- R.
❑Aquifer Recharge ❑GroundwaterRcmcdiation I•i.5ANIWGRAVRL PACK OfattttlieaMe►
.umt TO MATFRtai. ERN.afTMTNIMETHOD
°Aquifer Storage and Recovery ❑Salinity Ramer 2 it • 14 It, FILTER SAND i 2
❑Atli ifer Test ❑Stomm;it er Drainage -it. ft.
R.
❑Eepclimrnlal Technology ❑Slabsidcn c('unml .,, ilklt 1 I\i.LOG iattaci additional dwell'if iceman
OGeothennal iClised Loop) °Tracer room To DEMAI►PION,toter,Mardwe.t,..nMA nt.r.vim roc.rat.I
❑Geothennal IHeaunt''Cooling Return) °Other te'plaut under 0(21 Rein rknt 0 R. 5 R. FILL SILT AND SAND
5 R. 10 ft. WET SANDY SILT
4.Date Well(s)Completed: 6-1-24 win IDA&CIT-IA-MW03 10 ft 14 R WET SILTY SAND
Sa.Nell Location: ft, ft r^
•
USCG PEAS Site Inspection R. R S "'A� L• J nr,
r
Facilth.Otin r\.,,. Fscdm IDx i if arrilKahle'
R. R. JUL 1 2 Z024 ,
1664 Wseksville Rd , Elizabeth City, NC, 27909 R. R.
Ph%steal Address Cin.and Lip 211.REMARKS if..'•3IAK.,rr, ''—,- • ,,,
Pasguotank BENTONITE SEAL 1 TO 2' 611.....1i- 3
('oatan Prue(4l intftcd inn N. I PIN 1
Sb.Latitude and lunging&in degrecUmimitestseconds or decimal degrees: ,, Certification:
of well field,tut t:tfxutg is ndfkictal
N „ Brian Ewing 6/21/2024
�i,::utarc,,1 i.,aits:J t4,;1 l,unrnx,a Owe
6.Is tare)the well(+t: X'Pennancnt or ❑TcmlWoran Br*piing lhu tornr.I rereht-cerrefr that the u'ellol War form)cony/meted rm accordance
with 1.4 NC4C 02C.0/00 or 15A NCAC 02C.0200 Heft Commit Soo Starrlrirda and That a
7.b this a repair to an existing well: DI es or IS No •r' 4 r!t„re,,,r,}has h r.,,,• ,coca rn the„ex weer.
If aria ii a repair.(i/oat known Wee.rmt>apR rani tu/orn orron awl rytlrun the,iarwe of t0
rr}wirwder 821 remarks n-iion or-tan the hard of the pm. 23.Site diagram or Additilnal Neil details:
You nun use the buck of this page to provide additional well site details or well
8.%ember of weld constructed: 1 construction details. You may also attach additional pages if necessary.
}ar mahtple Injer'rse W nfmi-wan,,wipph wefts ONLY with the mie tamiaRrifea.t'oa(atrl
s i1anirmw fr,na. SUBMITTAL INSTUC'TIONS
9.TMal hell depth helots loadtlurfacer 14 (ry•) 24a. For .•11 Wells: Submit this I'mnn wnhm '1u dons of completion of well
For malnpk wells list all depths itdthlitemt le.0 mpfe-310:91)'and 241'IIA>•1 constriction to the following-
l1.Slade water kn el below toy of easing (ft.) Division of Water Resources,Information Processing I.nit.
ff MINI'kart r.,rh.'.r,array oar. " 1617 Mail Service Center.Ralcigh,NC 27699-I617
II.Borehole diameter 8.25" Oa.) 21b.for lnjcrtiem W'►ily ONLY: In addition to sending the form to the address in
23aabuse. also submit a copy of this form within ZO doss of completion of well
12.Well rriuetroctifn method:BORED col tslnuhun to the tollunt nip.
tic miner.rani-cable.direct pus(:etc I
Desblion of N'ata•r Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 NI ad sun ice I.enter.Raleigh.NC 2'611-l636
13a 1 uid(gum) Medved eft 14e.For'Water Soppy S.Injection Welk:
Also submit one copy of this form within :u days ofcoutplcnonof
IJb.Disinfection hpe: Amount: well construction to the count health dcpanmcin of the counts Is here
constructed
FormGW-t Nonh Carolina 11.Tunii. uofEnsImwirmandNaturalkesaurocc-DirrctonofWa4YReSotres I',.,.,:JAugust I;