GW1--04078_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD Foe tumid Use ONLY:
This form can tic used for single or multipk netts
I.Well Contractor Information:
14.WATER ZONES
Brian Ewing , rKOM TO b/M RtPI ION
Well Contractor Name R. ft,
4240-B R. ft.
NC Well Contractor fen ifcalion Number IS.OUTER CASING(for i olli-cased wells)OR LINER( as cable)
MOM itl otaMTTFR TONI:NTNS VI 411.11ta1
SAEDACCO n. fl. i..
Compost)Namt If.INNER CASING OR TUBING ijmitbcr ail deed-loop)
FROM TO -1'DIsME Ft N i Fill(101,1 )i V I NI U
2.Wdl CoutnietIon Permit I: 0 ft. 4 ft. 2 in. SCH-4 0 PVC
Lin all applicable well paned,ire.County.Slate.Variance.I iitaieIt en.i - 1 ---,
ft. ft. In _
3.Well l'w i cheek well use): ~11.SCR
EEN
VS Ater Supph Vs ell: MOM TO RIA111RTER MOT NOT luu Is'stNs %Iv1Nlai.
i1Agrwuhund OMwticipal'P bliC 4 R. 14 ft. 2 O10 SCH-40 PVC —,
I iGeothemtal(Heating�Cooling Supply) ORelsidetasal Water Supply(single)
R. ft. M.
I I hidustriat'Comnienial ORnsiden teal Water Supply(spired) a o GiW n
FROM To MATERIAL i ENRI ACEMIDIT METRO°a AMOUNT ,
EllmgaIion , 0 ft. 1 ft. PORTLAND POURED
ion-Water Suppy Welt: ft.
Rklonnonne ORecosrry _____.
Injection Well: n- ft.
❑,Aquifer Recharge °Groundwater Rcnicdiarion DRSANINCRAVRL PACK(11aptkak k) •
FROM TO INATRRIsl. rMPI.a(FMF'T MtTRnn
0Aquifer Storage and Recovery ❑Salina Barrier 2 ft. 14 h. FILTER SAND # 2
p Aquifer Test ❑Stomna;uer Drainage
R. R.
❑Erpennicnesl Teehnolot,+s ❑Sabsitden a('nnml
❑Cxuthemial(Closed Loup} ❑P 2A DRILUNG LOG tattaai adtlili.eal duets if accessary 1
t rocne F1aoM To DCSCRWPT1ON n.r.r,baed.e,r,irinwi.op,,tr..n..fl•,tel I
DGeothennal(Heatinatoolitig Retutnt °Other texplant under a'1 Remarks) 0 ft' 5 ft FILL SILT AND SAND
5 R. 10 ft. WET SANDY SILT
4.Date Welksi completed: 6-11-24 Well In0ECIT-HM-Is4W05 10 R 14 R WET SILTY SAND, ..
5a.Well Location: R. ft. It " �. a.+'L.�ii L.0)
USCG PFAS Site Inspection R. ft,
Faction OnncrNine Facllas IDE(if applicabk)
R. ft �UL 1 G �0?4
1664 Weeksville Rd , Elizabeth City, NC, 27909 ft. ft. I113:7;14'•:r7 '-c' •--Y J t
PM sisal Address,Cin-and Zip IL R[1NARIC.t CM C.SC.111
Pasquotank BENTONITE SEAL 1 TO 2'
Crunch P..rccl I.lcnisfmaion No IPINI
Sb.Ladlude and LaWRiamde in deg ees/minutrs.seennds or decimal degrees: 22.ratification:
(if well field,one kWloig is e4)k e)
W Brian Ewing 6/21/2024
Signii, I i_cndsd V.ctl tanlr.t.Ior Dote
6.h lard the wellls): R Pcnnancnt or I emlNlran ifs t,s,,.1e.liar form f htrr.M.-ern/v Mai the weld wits Iwrrrl sY,nrrrucred IS CtLIVnd(n9ae
with I SA NCAC O'C,O/Orr or l SA NCAC(rC.0200 Will Comoro,mot Sraodoufs acid dial a
7.Is this a repair to an esistiag well: IA es or K NO rapt'of thin record has brew proo4I ro she.,ell owner.
If rhlt is o repair,fill set Coyne w ell.mope/OM.iwls,rmaus,,i Mel a we's'the were of Me
repair aceder l2l rem ark%mans or on the had a(thir r,rn,. 23.Site diagram or additional well details:
You nay use the back of this page to pros ek additional well site details or well
8.Number of*elk easstrtected: 1 construction&lads. You min also attach additional pages if ttetessan.
For malrlpk injection.a mks-.,sore sappls wells Oh7.1 oat,mi.sent(congruent* .,:w;so
.s.brntrone Prin. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 14 ((t.) 24a. For Al Wells: Submit this fawn sit thm Ill dons of completion of well
For malrepk wails list oil drprhi ifdiflirrns irrumpk-44P:4)1i'and' 100'1 constriction to the following
II.Static water k-iel iwh,w Imp et rasher (MI bisiskin of Water Resources,Information Processing l nit.
1617 Mail Service('eater.Raleigh.N('27699-1617
11.Burchok diameter:8.25" (ta.) 24b.For Injection Wttb ONLY: hi addition to sending the form to the address in
»aabose. also submit a cop. of this form within tO dons of completion of well
12.Well a luanictian malted:BORED construction to the lollonutg
i i c auger.man. able.direct posh.emc.I
nit him'of Water Resources.lindcrmsnind injection Control Program.
FOR W%TER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699.1636
13a.Niel II Ielm/ WOW of test: 24c.For\laic(''uppls . Injection«'ells:
Also submit are stops of ihu 611111 uithui .t1 dais of completion of
lib.Disinfection q pc well Asatart well constriction to the count} health department of the count)niters
cots:meted
Font,(,U-I Nord Carolina Department of Em iloultcsu and Natural Resources-Dr:woe of V.al,r Nmotrces Res red.august NI l l