GW1--04084_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For!mental Use ONLY:
Mrs form can be need for single e!tnudlipk wells
I.Well Contractor lnfurnlathrr:
14,WA16U7)NIS
Brian Ewing Mil I TO oeslinotiON welt common.('otmrtcon.Nana; ii. ' fl.
4240-B It. Ft•
NC Will Comractcir Cenifiialan limiter 15.OUTER CASING(her m.Mi•cand netts)OR LINER 11f as hcakkl
MOM To DIAMTtrn Toot:si s MATTNRL
SAEDACCO Ft. fl. in.
('ompuONang If_INNERCASING OR TUBING lyeothnratdawed-forgo -- ----
fpONl 1 to 111 eNIF frH T111CK\E.\ MNI►HI AI •
2.Wdl Coes*rvctinn Permit Nt 0 ft. 2.5 ft. 2 h. SCB-40 PVC
1.1.0 all wpph.-tile well i ennrts fLe.Canty.Srwar.Variance.friar*,etc., y ... .. _ :
rt. n. 1 Ni.
3.Well lire(check well rink 11 st-Hit N
Water Supply Well: nNN1 In • 01AMIFTt.11 siot�rn nor I OS, NISTrRIs1. :
IJAgrictilRural OManisipal+A►h!c 2.5 ft. ' 12.5 ft. 2 ire 010 SCH-40 PVC
I IGeothem►al(Heating:Cooling Supply) OResidential Water Supply(single) R. ft. in.
I I lndustriaLComnnercial ❑Residential Water Supply(shared) 11`GRO
FROM TO MATERIAL.. EwPIAl f Nr\T 4f II1011 A N%1411\TH
❑ko►gatton 0 ft. 0.5 ft. PORTLAND ;POURED
Non-Water Supple Were: rt. ft. I
XMotutonnt; ❑Recover• -_--.
Injection Well: ft. rt.
❑Aquifer Recharge ❑Gmundwater Remedial ion la.SAND .:RAVEL P.A('K DIaNBesele)
tIovi iu NI%TERM!. r IP1. WT%1rvt MrtllOn
CIAquifer Sloragc and Recover ❑Salinity Barrier
1.5 fr 12.5 n, FILTER SAND # 2
Cl Agnifcr Test DSlomwsatcr Drainage
n, n, 1
❑Egicnnlrnl►1 tahnoloGc ❑Suhsidcrcc Comm! 111,t►RII.LING LOG(atl&m ilienal Ames/nrtwsalrsl
❑Gcuiltennal lC nosed Letopt ❑Tracer . FROM 10 DESCRIPTION tool's..lowdoota,.iitn,.t.ti.,.t:..n wry.tit.'
DGeothennal(Hiatnnit oolitiY Retulnt OOther(explain ulstet 571 Remarks) 0 ft* 5 ft. FILL SILT AND SAND
5 lb 10 ft. WET SANDY SILT
4.Date Weil(s)Completed: 5-31-24 Well'rya ECIT-0A-14W03 10 n. 13 f1 WET SILTY SAND
5a.Well Location: it. h L- _ ,' • ` ` '
�..•L. s,..
USCG PEAS Site Inspection n it.
Fa:tln.Oa ter Namc Facility IDS(if applicable) II n. JUL1 a 2024
1664 Weeksville Rd , Elizabeth City, NC, 27909 Ii . n. , 1.r^, ;t t,)PA,
Plnsical.Address_Cite"and Zip 21.R1.Si ARK. D'h r.,ii}!{.•ti
Pasquotank BENTONITE SEAL 0.5 TO 1.5'
haro:1 tdcnrtfcAtinu Nu IPI\I
Sb.Latitude and longitude in ikLrresiminutcs/scconds or decimal degrees: 22.('c ficatina:
tto wail)field.OM Lw•Ititlf ix%WiiceInf
W Brian Ewing 6/21/2024
Signalise of Certified Well Contractor fkilc
6.Ia(are)16r welts): 7CPeniianrnt or femp Oran By nailing rho tome.(hereby certify fiat the nylks)ttwer(nrrel ennoructed is accordance
wit*1 Set NCAC(12C.0100 or 1 M NCAC 02C.0200 Weil Constrarriatl Struwfard'and rlwu a
7.Ia this a repair in an esistiag well: Li Yes or X No rnytr of chit rrrnnl ion hero provided to the..ell rrwvler.
1fl44 u w rrpnir•fill mg inarna a.41 a 0411/nr bent Mftlrcouu sot anti a i/,gun the natant of the
repair ander 221 remarks.,n.ii m or on the bark of this form 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You Inlay also attach additional pages if necessary.
for mwlvplr anjrrrhtn.n rraat•..•Fur,.upph treat ONLY wads Cl, same ewavrwrw,wt •...w can
salxttir one h•nn. SIIBM ITTAL INSTIJCTIONS
9.Total well depth Mon laud sulfate: 12.5 (ft l 21a. Fur All Wells: Submt this fonn within 1t) days of completion of well
tot maniple teams US'el ATM,(I deftrr,.o i.o aipfr- ca.''t. .::..i', !.a,t constnlgion to the foltuwing-
IS.Static water level blow 1mi Ocular (ft.) Division of Water Resources,Information Processing I nit.
If twit+:1,.1 r,:Akmt,as ag.Ytr"." 1617 Mail Service('cater,Raleigh.NC 27699-1617
11.Borehole diameter:8 Oa.) lib.For Injection Welt ONLY: in addition to sending the loon to the address in
24a abuse. also submit a copy of this form within TO days of completion of Well
12.Well ceut$ntction method:BORED constmctiuu to the following.
lie.auger.roams.cable.direct push erc.t
Division of Water Resources,Underground Injection Control Program,
FOR W 1TFR SUPPLY W'FLLS ONLY: 1636 Mail Senior Center.Raleigh,NC 276994636
13a Field IEhnt) Method of test: 24c.For Water Suppls 8 Injection Wells:
Also submit one cops or this loon %%Ilion iO days of conviction o
tab_Disinfection h pee: -kimono: well construction to the camp, health department of the c ts oun where
constructed
F,.,r,I.:'A-I Nook Carolina Llrpannlew of Ens irotutictu aid Natural Resources-Divscioa of Water Realms Res wed Aoglrst ill 11