GW1--04087_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For Infernal UscONLY:
Tins form can M nsod foe siuttle or mullipk uellc
1.Wdl Contractor Information:
t4,WAIERzot L4
Brian Ewing PROW TO D t(9tIP110t1
,Well('nrarlctot Nancy R. ft.
4240-B ft. (I.
i
NC Well Contractor Ccnilk.1ion fr miter
15,OUTER C,ASPIC MirnuMi-eamf wells)OR LINER iY applicable)
swow i ro DItMTTra TRICKNTsti 1,141TRI%I
SAEDACCO II. j tt. in.
('aulfl.i ns \.Ink It.INNER CASING OR'11 BING ljeuth,raul cluse4-litr)
Ui or ssrF ri n rtnt k\FN." NI UrRfAI
2.Well Cnostnictinn Permit I: 0 ft. 9 rt. 2 in. SCH-90 PVC
Lst oil apphi ably urn pennies(i.e.County.Smhr,Varian.littbeiett ri.1
ft. ft. in.
3.Weil hoe(cheek well nee): 1'.a RCEN --
Water Supply.Well: ' FliONI Ill RtAsnTra Slut mutilk Is5FN, vstf RI Al.
11Agricultural DMwficipaUPubliC 4 II. 19 ft. 2 010 SCH-40 PVC
11Geothertrol(thank/Cooling Supply) OResidetxial Water Supply(single) /t. I ft. to j
11lndustriaL'Comn► vial OResidential Water Supply(shored) Nk G4lOUT 1
PROM TO MATERIAL. EMPLACEMFN-I%If.MOD A AMOUNT
Dfrnpation 0 ft. 1 ft. PORTLAND POURED
Non-Water Supply Well:
le Mon tonne ❑Rccosrn R. ft
It. rt. ,
iiajectlttw Well:
DAgiifcr Recharge ❑fimimdw;a;cr Rcnlediation j I!.SAN91lAlAVHL PACY fir applicable)
CR4►M TO 14it1Rtat. WWPI:s(rWv\T%ITHon 1
DAgtafer Storage and Recovery ❑Salina Barrier 2 R. 14 ft. FILTER SAND # 2
DAquifer'Test ❑Siormssatcr Drainage
R. R. i
❑Egrrtmrnutl'Tahaoloyn ❑SrYssudcncc Control it LNG LOG(atlreh ail itlatld sheds if eecessarst
DGeothenmal(Closed Loop' ❑i racct PROM TO BESCRIPTIO11o►lie.hardier.,to sk icktyre.vse,vac etc(
D nnGeothe l(Ilcattng+Cuoliig Return) Wilier(explain under#2! Reatml.$) 0 R. 5 fL FILL SILT AND SAND
' 5 ft. 10 ft. WET SANDY SILT
4.Date Wells)Completed: 5-30-24 Well IDsECIT-NE-MW02
10 R. 14 tL WET SILTY SAND
Sa.Well Location: ft ' ft
USCG PFAS Site Inspection R. f ,.T F....R�F r
Fa:tlm Oa err Name Fsciim tDNInapplicable) R. ft.
1664 Weeksville Rd , Elizabeth City, NC, 27909 ft..' ft. '
Plnsied Address-Cio-and Zip 22,REMANK$
Pasquotank ' BENTONITE SEAL 1 TO 2' 11F�s.RG"ss►et . 'iltl
('.an A• Parcel!don't-me:0441 W IPINI
Sh.Latitude and Longitude in degrces/minotes.Isccnnds or decimal degrees: 22.(ertifratkn
(tiwdi field,one Wines is sueicien1)
N 1\ Brian Ewing 6/21/2024
Nlt,l.,, I I_cntl-,:d s..I(.mrcnkr Dale
6.is(art)the*tilts): %IPermanent ur ❑Tem(Rsr.sry gs,r;•,.',:this loom I hereby certify that she*eyelid was(were)cymrtn:end in accordance
with 154 NCAC 02C slot St or 1.5.4 NCAC(12C.0200 Well Ceastractian&waded(and them e
7.h this a repair to an existing well: ._i Yes or ID No Loon n(thi(re(ord late her/t provided to the urU owner
if doe if t Ieprne.fill.nit ktl'tet net I frn)i at 11rM InfartlkrSNl mu/et'p(aln the aerate Of the
repair order l l rem.erie erseienr or on the hall of this form. 23.She diagram or additional well details:
You may use the back of this page to pros ide additional well site details or well
8.Number of wells eo rtlet ed: 1 colWlniction details. You rnas also attach additional pages if necessary.
For nndtlpk anfr(rhnl or room-water)apply wells ONLY wait the rime rIastear Ylaa war rem
Admit one Pm. SI IBM 1TTAI.iNSTUCTION S
9.Total wdl depth below lard surface: 14 (h.) 24a. Fur An VW'dls: Submit this form within ?u days of completion of well
For malrtpk wells hit t(l.t,-,oh,ifdfffrrent(example-J4100'eat 2fr losT) construction to the following
IS.Stadew•ater itsel below top of casing: (R•) Division of Water Resources,Information Processing l nit.
if infer level if ahr,ye,osiog.ux , 1617 Mad Service('cater,Raleigh,NC 27699-1617
II.Borehole diameter:8.25" Gael 24b.for Inieetlea Went'ONLY: in addition to sending the form to the address in
24aabose. also submit a copy of this form within 10 days of completion of well
12.Well corn rwetittn method:BORED construction to the following.
(i.e.auger.roars.cable.dir(n push de.1
Dhision of Water Resources.Underground Injectlou Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Set ice Center.Raleigh.NC 27699-1636
13a.field(mot) Method of tat: 24c.Fur 1Fatcr Sapph A.Injection Wells:
Also submit one copy of this form w Ohm 3II day s of completion of
13b.Disinfection type: Amount:— well construction to the county health department of the count'white
--- consliucted
Fenn GW-1 Nonh Calcium Dgssnnriu of Em ttotulrmu ant Natural Resources Dts es ion of W atcr Resorro6 Reseed August NIA