GW1--04080_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD P«Menial Use ONLY:
This form can he used for single or multiple wells
1.Wdl Contractor Information:
14.WA1181110=11
Brian Ewing PROM 10 pent 01.110t
W.:11('nnncb,r N.rne ft. ft.
4240-B R' h"
NC Wdl CorntmctorC tidiemion Number1B OttTH CASING(for ttwMitascd wain OR LINER Of able)
FROM TO n({NTTFR THICUNTS5 I H5TTp151 —�
eAwnaccO It. r. ia.
C Name 11.INNER CASING OR T 'LING oral clove/•loop).
FROM TO f DIAMETER HHK'M'FSS Ml1 UNl\I
2.Well Coaatrioction Permit 8: 0 R. 4 ft. 2 IL SCH-40 PVC
List all applicable..r8 permits(i.e.County.Stair,Variance,liOn,elf., - ill.
3.Wdl Ialf(check well oval:
17,SOWER
Water Supph Well: nem TO DI<5KTTR sl.m WI THICriN155 NI 11IRt.5I
C1Agt><uhutal OMunitipal:Arbhc 4 R. 14 It. 2 io. .010 SCH-40 PVC
1 1Geothemlal(Heating/Cooling Supply) °Residential Waler Supply(single) ry' h is
17lnduslrialtComnlenial °Residential Water Supply(stetted) la.CROt7T ro MATERIAL ' EMMACYMENT WINO°a AMOUNT
Dkrigation 0 ft. 1 fL PORTLAND POURED
Non-Water Supply Well: R. ft.
Rklonitonnc ❑Recotrn' ____.____-- -- ,
Injection Well: n- ft.
.
°AquiferRecharge °Groundwater Remedial l,1, Iv.iANDiGRAYEL PACK Oltaponcable�
FROM TO M&TURIAI. r'MM.t(TMr\T METHOD
°Aquifer Storage and Recovery °Salina Barrier 2 ft. 14 Cl. FILTER SAND # 2
❑Aquifer Test OStommater Drainage -
ft, ft.
❑EdtpenmcnLvl Ttxhnnlogy ❑Shcsiderrcc Comm! :1 inter I1 t tAK.(attach additional sheets Oameousnt
°Geothermal(Closed L oopl ❑Tracer FRUNI i To DESCRIPTION Ruts.besot...witmck 13 pt.gran.et•.ctt-i
°Geothermal(Heating+Cooling Remo) °(tepee(explain under I(21 Rctnatks) 0 R. 5 ft FILL SILT AND SAND
5 ft. 10 ft. WET SANDY SILT
4.Date Well(s)Completed: 6-4-24 well mgECIT-AR-IIW01 10 ft„ 14 n WET SILTY SAND
58.Well Lalcatiin R. h. '
USCG PFAS Site Inspection it. ft. 1 ii •r 1
Faethts.'OnrcrName Fxilih IDs.ifapphcabkt - `� ►r ~- -�-Al..R � 'L
1664 Weekaville Rd , Elizabeth City, NC, 27909 R. ft. JUL 1 % 202.1
Pln sical Address.fin.and Zip 21.RIMARKS
A
Paoquotank. ENTONITE SEAL 1 TO 2' irI 7!.k. s s1' r�-r^yty(,--.t
(' unI Parcel kkuliriceinr Ni,Nn t PIN'i D'A C.SC4
5h.Latitude and lanjitwde in degrecsiminates/sccnnds or decimal detrrers: L7,certification:
(tfll fie
ld.no tacking is% l'tcrc.a l -
N W Brian Ewing 6/21/2024
Signatory of Ccndtcd t4'cll Contractor Dane
6.Is tare)rite welllsl: X'Pennawcnt Rr 111Temporon N signing An teamm.I hereby certify that the urasl eat(enorl cvmrma•ted in atsunhaonr
with 154 NCAC OW.0100 or 1 SA NCAC(1:C.0200 Well Constrac non Standards and that a
7.Is this a repair to an existiti.itch: LiYes or ENO ,.fir of this trend Aar been provided to the rill owner.
if this rs a(('pleura fill WO let o..wall.<ntstrut roan rnfurswriwt nrnl a(p&.m rh,nitrate of the
repair ruler 121 remarks.section or on the hark of this form 23.Site diagram or additional well details:
You may use the buck of this page to pros ode additional well site details or well
8.Number of weNs conearrltted: 1 cottsttut:non details. You may also attach additional pages if necessan.
For toxin*rgfecrhon or rout-sorer swppdr welts ONLY with the some ceeutraetfae,won ton
submit one fora. SIIBMITTAI,INSTUCTIONS
9.Total well deph below lardtotface 14 (ry,) 24a. For Ail Welk: Sd1m1 this fano .ohm 1(1 days of completion of well
For maniple walls list oil depths ifdrffirent re.raanph•-1€200'and 2€'1oMY( construction to the following-
It Static water Revel below fop of cashes (ft.) Division of Water Resources,Information Processing t nit.
If*trier level is ahoy twang.tyre"a" 1617 Mail Service('cater.Raleigh,NC 27699-1617
11.Korebole diameter:8.25' (lis.) 2.lb.For Inimtion WeI%y ONLY: In addition to sending the form to the address in
2laabuse. also submit a copy of this form within 10 days of completion of well
12.Well coostrnrNon method:BORED cotsrmctimr to the tollowing.
tic.auger.ratan,cable direct push cleat
Division of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1036 Mail Sen ice Center.Raleigh.NC 276994636
13a Yield ILT(trl Method of ' 24c.For Water luppli &Injection Wells:
Also submit one cop of this fora 'salmi nil dais of completion of
I3h.Disinfection n re: Amount well constnichon to the cotmn health deportment of the cousin where
constructed
F.ro.(rU-I Noel Carolina Department of Ens nonntenu and Natural Resources-Division of Waicr Resotrcn Revised A&g st 2o13