GW1--04083_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For Menial UscONLY:
PIN f,rnr.:an Ir uwd for stank or multiple wens
I.Well Contractor htferniatioo:
II.WATER ZONf3
Brian Ewing 1/11O14 TO M1CRIrt1Fxl
Well('nlII ioitt N.anre Q. rt.
ft
4240-B
n.
NC Well Contractor edification Neither15.OUTER CARINGAir mottl eared wells)OR LINER 4It apphcabkt
FROM TO M{MFTFR TOR'N\F\S 'l{TFRI{I
SAEDACCO II' ft. I..
Compaq N;.nrc K.INNLR CASING OR%USING(yrrderral closed-loop) _
r1OM TO at{MF VTR (ell(A\F�s N{1FN1\1
2.Well Comae/wetinm Permit II: 0 ft. 4.5 ft. 2 in. SCH-40 PVC
Liu 41 applicable wr)I prnnas list.Como.Slay.Variance.fiaWQf rent R. - ' is.
3.Well I s'Icheek well awl:
17.SCRUB
Water Supply Nell: /ROM TO i M{MVTFR It.O1311i nmi 10I-. NI(rlNIsl
DAgricultutal DMmricipal.Pubhc 4.5 R. 14.5 ft. 2 010 SCH-40 PVC
❑Geotheal(Heating/Cooling Supply) ❑Residential Water Supply'(single) ft. R irkm 1
DbtdustriaUComnlercial I lResidetttal Water Supply(slamd) It GROUT
F'RO'4 TO MATER[AI. EWPL{CEMF\I\1F 111()n A AMOUNT
❑Imgation 0 ft. 1.5 ft. PORTLAND POURED
Non-Water Supply Welt:
RMmutonnr: ❑Recover _--.
Injection Well: It. ft. '
C1A1infer Recharge OGroundwatcr Remedi:ut„I, I'r.\\\tl(.R\\1.1 l'{(I. it j.11a.l.lr, -
.1411,1 nil ,I.n RI\I ►MW.{IFMEVT MI?NOn
❑Aquifer Storage aid Recovery ❑Salinity Barrier 2.5 II 14.5 n. FILTER SAND % 2
El Aquifer Test DSlotmwater Drainage
a. n.
❑Eyperimrnlal Technology OStlbsldnte(carol 24, 1)H II 1 IN 1.LOG(atacb additional duets it nece.vn i
❑GeothermalIC'IusctiLoop! ❑Tracer FNo\I _ to osxiIPTIO\I...l.r.lr.cane....au'nnk(Irr.xrra.rt.ear.)
~❑Geothennal(Heating(.'ouliug Return) DOther(explain under tr21 Rematts) 0 fr. 5 fl FILL SILT AND SAND
~5 Ii, 10 ft. WET SANDY SILT
4.Date Welke I Completed: 5-31-24 _WdI IpgECIT-OA-MW02 110 m, 14.5 IL WET SILTY SAND
5a.Well Location:
m. n.
USCG PFAS Sit. Inspection It n. 1. ,. s I{
Failed''On ncr Naar Facility ION(if applicable) ," '�"*
rl. ft.1664 Weeksville Rd , Elizabeth City, NC, 27909 r h. f n. JUL 1 2 2024
Pinsk-al Address.On.and Zip 21.REMARKS -
ri
Pasquotank BENTONITE SEAL 1.5 TO 2.5' 4 "'
r.,II is P.ucil Identification No INN
.h.Latitude and Longitude in degrTrsiminutcusecnnds or decimal degrre: 22,('ertificatiom:
(ii welt field.Inc t:R le)»g tx ndfrtrcao
N W Brian Ewing 6/21/2024
Siguatint of Certified Well Contractor Date
6.Is tare)the we(Its): HlPennancnt ar 7-1Temporars
M-marring etm loom I hereby.ernes that the*Wits,war(*err)constructed m accordance
a'AM 154 NCAC 02C.0100 or 154 NCAC n2C.0200 Well Construction Suuafards and Mai a
7.Ia this a repair to an existing w cN: _:j1'es or R No r.pr o,tiv,r.•.-nni has hr.n iron sled rn the erfl owner
If Of is It a teptar.fill OW fuUµa µ nil."min*Puns Nfgorn arum Ilad r.cpfahn ncc notate of rho
repair corder 021 re mach.rr,ucnr or on the hack of MC,I,rin. 23.Site diagram or additional w ell*falils:
1 WI tn*t use the back of ills page to pro\Nei additional well site details or well
8.Number of weir twuutructd: 1 construction details. You rimy also attach additional pages if tlecessan
for malrrple nnje•rrhat of hMl-µalter writ wefts ONLY ntrn IS,swat C,Notrlwhui v.0 earn
Iarbmnrrvrr form. SUBMITTAL INSTUCTIONS
9.Taal well depth below laud surface 14.5 (B.) 24a. For MI Wells: Stfbnrl this limn \uthm iU days of completion of well
For muftipk urns list eeg depth,if&Orient tramrlpfe-30200',u41,,' f0(I) construction to the following-
it Static water Intl below top of cashew (ry.l Diy isiln of Water Resources,information Processing 1 nit.
ft noun kin/it rdkmr r aslaX.Mk'-,.. 1617 Mail Service Center,Raleigh,N('27699-1617
II.Borehole diameter.8.25" (Id) 21b.For Imjeetiem W'elb ONLY: In addition to sending the form to the address in
21a abuse. also submit a copy of this form within :O days of completion of well
t2,Well cowatructiln method:BORED colrslrukiion to the following.
a c ao;xr.roan.cable.dircel push etc I
Diyhion of Water Resource).Undergmoind Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail See ice Crnter.Raleigh.NC 276994636
13a !loll I>%Foil Method Obit:
Iac.Fot'Wafer Suppy &Injection%%ells:
- Also submit one copy of this loon witlun 31. da\sof completion of
136.Disinfection n pet: Annelid:_ well construction to the county health department of the county where
conalnictcd
Fonn GW-t North Cato fun Dgimrnrm of Ens rmtutriu and Natural Resources-Dn sioa of Warr Recurs Res toed August loll