GW1--04086_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For lcrl Use ONLY:
The form Call be used for cim•k nr'maiiplc uas
I.Well Contractor Information:
It WATER ZONES
Brian Ewing ►aust TO OM'RI►T ION
Well(',a*ncu•r N"note W. R.
n, R.
4240-B
NC Well Committer Certification Number IS,OUTER CASING(for osMl-Came*ells)OR LINER tlf likable)
mom TO DTANrTFR TTIN'KNTSS %VatNthL
SAEDACCO ft, fn. ill.
Campus)Name Ie.INNER CASING OR TL'RING(sa'anbeneal closed-h ep)
FROM 10 T{ DtRMF TER rhIfk%FAS ‘1%I{NI kI_
2.Wen Conutnrction Permit#: 0 R. 4.5 ft. 12 M. SCE-40 PVC
llu al apply able wrll penmr.tier.C?rant. Star.I:ariam r Injection nr.+ -- t
ft. i ft. 1. its.
3.Well I'm(check well use): ;
7.S('RtJLN
Water Supply Well: Pl_,t TO loco:Tt a,olsin I lilt 1..1.. NI111HI.1
❑Agrwoltural ❑MunicipatPublic 4.5 A. 14.5 it in. SCH-40 PVC•
❑Geothcmul(Heating)Cooling Supply) ❑Residential Water Supply(site) u. n' la.
❑htdusttiaiCommercial ❑Residental Water Supply(shared) lR 1 0T --
FROM TO MATERIAL. EMPLACEMENT M{I1111U A \MOUNT
❑hngation 0 ft. 1.5 ft. PORTLAND POURED
Nan-Water Supply Well: —
R7Monatomic; ❑Rcco rs
Injection Well: I ft.
[_I Aquifer Recharge ❑Groundw'atcr Remedial ion $4.SANRfGRAVRLPACE Of vpIi.W,bl.•;
❑Agaifcr Storage and Recovery ❑Salinity Harrier1 PROM TO M iTF."RI si ►MPL CTINVAT Mrrmion
2.5 R. 14.5 ft, FILTER SAND # 2
❑Aquifer Test ❑5t011 McrDraint(age ft h,— .
❑Expcnmrnt tl 1"ahaologs ❑Sabsidctrcc C'aarol N.DRILLING LOG fatted aMWaeal sleek if nrccssan)
❑Geothentall Closed Loop) ❑Tracer ►ROM TO DESCRIPTION itwler',wardurw,,ain'nwko pt.osto ie.dr.I
❑Geothemal 1Heating'C'ooliug Return) OOther(explain under#21 Remarks) 0 R. 5 IL FILL SILT AND SAND
5 R. 10 G. WET SANDY SILT
4.Date Welts)Completed: 5-31-24 \Nt4i'Ds EC IT-OA-1E404 10
fl. 14.5 ft, WET SILTY SAND
_ —
Sa Wdl Lucatinr —
ft. R '
�- _,.b_a a„ 't l t.
i -s s I...L.
USCG PEAS Site Inspection h. ft. 1{ 1
Facile)N net Naw,, Faciliq ION(if applicabk) ri f It. Jut_ c G 2024
1664 Weeksville Rd , Elizabeth City, NC, 27909 n. � - i
Pin neat Ad less.City.and Zip y 13:T.4 c, +
�
'.1.REMARKS pr&'C,i4Ui;
Pasquotank BENTONITE SEAL 1.5 TO 2.5'
I lra+.I: Parc1:1 llem,fit:aiun Na I PIN1
Sb.Latitude and Longitude in degrees/minutes/seconds nr decimal degrees: 22.certification:
of well field,me la lag k sufficient)
N W Brian Ewing 6/21/2024
Signature eCemled Well Contractor Dote
6.Is tare)the went* RIPennanent or ❑Tenporary in tihrting lhu taonr,1 hrrrh;rrrrrfi'that the weasl,want(wrrr)eonarurtcd in accordance
with 154 NCAC 02C.0100 or 15A NCAC O:rC.0200 Well Construction Standards and that a
7.Is this a repair to an austiog well: 0Yea or ENO w,xrr of-Ai:«wont has hrn,pr.o.ded to.the t,r/i nwwr.
If'hi s+.,++guar fill isr ha,+we wrll,t,M7I1,/sets+nforn„,roa,atwl rrp)w',dn.nature of rlw
repair am?rr I21 remarks.r,ti.w,or am the hark of this form. 23.Site diagram or additional well details:
You may use the back of this page to pros ide additional well site details or well
S.Number of wtt:lb cnRatm1ed: 1 construction details. You ItaN also attach additional pages If necessary.
For nralripk rnf etton re WW1-outer supply welt:ONLY with the tea,.coaorwrriou ,..,n,„o
whorl one fnrar. SI IBMITTAI.INSTUCTIONS
9.Total wdl depth below lard surface 14.5 (R.1 21a. For Al Wells: Submt this form within 10 doss of completion of nell
For mahlpk wells Ito all depths Ifsat*rent/r.onnpte.t6t•:,00'tinS?e4,hill consiniction to the following-
le.Static water level below top of casm;;: tuts Division of Water Resources,Information Processing Unit.
if wilier kit/n,ti'.rt tasim, :,•. • 1617 Mail Service('carer,Itakiuh,NC 27699-1617
II.Borehole diame er:0.25" Oa.) 2-lb.for Injection Weib ONLY: In addition to sending the form to the address in
24a abuse. also submit a copy of this form within 't0 days of completion of well
I2,Well calatroction melllod:BORED construction to the following.
41.e.Mgt.Man,cable.direct push etc.I
Ohisinn of Water REUNITES.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699-1636
2{c.For'cater Suppl\ S Injection Wells:
13a.\lentil(men) Nit•thud of test: _-__
Also submitt one cops of this furor within 10 din s of completion of
I311.Disinfection type: Amount.: well constnlction to the counts health department of the counts where
constructed
Fenu(1W-I North Calcium f>sv,narta of Em imauaall aid Natural Resources-Dusan of Water Re cnrea Res set August 2011