GW1--04077_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For Intermit Use ONLY:
The form can be oscd G.r sink or multiple nen,
I.Well Contractor Information:
II.WATER ZONES
Brian Ewing ►ao' to tans RI TN►N
Well Conlracior Name n. n.
n. n.
4240-B
NC Well Conaractor Certification Number 15.OUTER CASING(far omMl-caed was)OR LINER tU an likable)
FROM TO M;NTTFR TNKl0Tc5 I M'TTNT{I.
SAEDACCO n. n. is. JI
Coll pt al Name IS.INNER CASING OR TUBING Agiodierasal clowdriwlt)
room to DI{MTTFR TaKiNF\5 {I%IT RIM
2.Well Coutlttictioa Permit ii: 0 ft. 3 R.I 2 ill- SCR-40 PVC
List all applicable well permits tie.Cawrv.Sao',l',tnuuce Irfeceat err.1
R. ft. O.
3.Well Cue(check well use): 17.SCREEN
Water Supply Well: FROM TO attwwl a MOT 517/ ( Tam hNdN, Stttlwt.i,
LIAgricultural DMnnieipat'Public 3 ft. 13 (h 2 O10 SCH 40 PVC
Geothemtal tHeatin ,CooN rt.
ft. is
fI g a8 Steppes) OResidcrRial Water Supply(single)
I.lindustrial.Comntercial OResidential Water Supply(shored/ n'
PLOW TO MATERIAL. EMPLACEMENT MEMO A.AMOUNT 1
❑krigatton 0 it. 1 ft. PORTLAND POURED
Non-Water Supph Well: ft. n.
RMarutonne ❑Recovcn
Injection Well: n. ft.
[IAtltoke Recharge OQroundwater Remedi;aion $9 SANON:IAAVELPACKfitaplicable)
❑Aquikr Storage and Recovery ❑Salirlily Ranier FROM to M ATPRI.st. fit ATTMENT MI-TIIOI
2 n. 13 n. FILTER SAND 9 2
❑Aquifer Test OStonnw:Rer Drainage n, ft. --
❑ENpenmcntal TechnologY OSabsidertcc Control
—
iR SWUNG LOG latlacll addiliawal{lint{if an:essars 1
OGeolhemial(Closed Loop a ❑Tracer PROM TO OEM-RITTtONraolor.►ardacw,wd'nw-la not.grate fw.elt.1
DGeotlaemwl(Heating''C'uolitlg Retuml OOther tchplain under N2I Remarks) 0 ft. 5 n. FILL SILT AND SAND
5 ft. 10 n. WET SANDY SILT
4.Date Well(s)Completed: 6-11-24 ‘10..ii IDNECIT-HM-I4W08 10 n 13 ft, WET SILTY SAND
Sa.Well Location: ft. ft. E`7 . , �.`•vCr, ,•
USCG PEAS Site Inspection R. ft
Fatbts.Chi net NaII. Faction lOkrd•appla:ahi, - JUL 1 2 2024
rt. n.
1664 Weeksville Rd , Elizabeth City, NC, 27909 n. ft. lfr i:1r.4,C'-r,,. 4-,•.'": c,t tI4
Physical Address CM.and Zip 1-2i.REMARitS -1)41.:0 it.^;
Pasquotanle ' BENTONITE SEAL 1 TO 2'
Comm Parcel ldcnlRrtlinnNr' a PIN I
Sh.Latitude and Longitude is deZraeslmbastesisccnnds or decimal degrees: 22.I.cnificatioa•
Ili welt field.one I:u.long Is saatnerenl l
N W Brian Ewing 6/21/2024
—Signd, •I lertdtcd Well Lome-root Dote
6.l tare)the wrll(s): X Permanent air '7Temporar- Br ins",'dais form.I kerrbv certify that the wrd(al antes(wetrl ertasrrve Led IR arorda ce
wait I 5.4 NCAC 02C,0100 or 15A NCAC 02C,0200 Well Consuwc r on Slraada,dr and that a
7.Ia this a repair to an csistiaR mat: =i l es or III No cells.of this rr.,.nf ha,brew provided to the caul!owner.
11l64 is ei repair,fill err known writ 4[MAMA rah,a.,Ioernor o t and Apia the'ware of the
repair aader I21 rewwntc.wa ghat Of an the hack of this-farm. 23.Ske diagram or additional well details:
You may use the back of this page to proside additional well site details or well
8.Number of welt coostracted: 1 construction details. You nuns also attach;I/Mammal pages if necessan.
For nudnpk trljearhnt an men-.rare,aaapph w e8,OW.t wrfir rile Wale cawruraelion WM an.,
rrdatirnew Jana. SUBMITTAL INSTl1CTIONS
9.Total well depth below laud surface: 13 (n.l 24a. For All Wells: Submit this limn nuhm zu days of completion of well
For rnwhrpir w rlh hAt oh deptht rfdtftererrt t eaamtpfe-f'(29O,and'ia 1110) eonstni tian to the following
10.Static water level below tap of abhor (n,) Division of Water Resources,information Processing I.nit.
!!wafer le.el n(those,ostme awe.,4., 1617 Mail Service Center,Raleigh.NC 27699-1617
IL Borehole diameter:8.25" tin.) 24b.For lniceltia Weft ONLY: hi addition to sending the torn(to the address in
24a Aim e. also submit a copy of this form within k)darts of completion of well
12.Well cuuwruction method:BORED cotutnuiion to tine follow tog.
tic.auger.roan,cabk.direct pith de,
Desisinn of Water Resources.underground Injection Control Poagrant,
• FOR WATER SUPPLY WELLS ONLY: i tot.%lei/Sera ice Crater.Rakit:h.N( 2'699-I636
13a.Yield(Rpm) Itit4had diets/» 24e.Far IN liter Supph &Injection Welk:
Also submit one cope of this loon nilltro .rt dm s of completion of
13b.DWafecfius type _ ._ Amtmab well construction to the countt!, hcahh department of the counts nitcre
consmictcd
FonnGW-I NonbCaroluiaDepunnrtuofEmtrrrur►7aaidNaturalResources-DINscionofWaterR6otrces II,,,,,d tuguu I