GW1--04088_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD For'mental lReONI V
Tim form can be used for singe or nlultipk nclls
I.Wdl Coatrarenr Information:
11.WATIRZONIS
Brian Ewing FROM tO 1 DEM•RIPIION
Well Contracwu Name h• ft.
4240-B _ h (I' I
NC Well Colo filltir Certification Nun ia r 1 IS.OUTER CASING(ler alsNi-essed eels)OR LINER of se Stable)
FRON TO MAMMA TRt('kNFs. MATFRIII .
SAEDACCO ft. II. in.
Comps,N.Ellt 1. lie.INNER CASING OR Tt'IING tgeerhTral clesedaoop)
. FROM - to nt yS1►TF N ('A IfiINFNS M.41l Ri.li
2.Well Construction Permit N: 0 ft. 4 6. •2 is SCH-40 PVC
llu all applii obi,well permui ir.r.('ownn- .State.Varian-,blernarl ell .'
fie. O.
3.µ'ell 1 se icheek well use l: t'.N(RIIN
Water Supply Well: roost ell M'NFTPR MOT SITS I Tftte-tovi. I MATRRtat. ,
4 ft. ! 14 ft. 2 iI I Agricultural ❑Municipal.Atblic
a, .010 SCH-40 1 PVC
I Geothermal(Heating,Cooling Supply) °Residential Water Supply (singlet
h. . R. in.
I I IndustriaLContmcrcial °Residential Water Supply isleired t I IL GROUT
FROM To MTERtkl. EMPLAC MVIT MrlRao a AMOUNT
CJkngation 1 0 ft. 1 ft. PORTLAND POURED
Non-Water Supply W'eN: I
p, ttXklolutonnt: ❑Recovery - •—
Injection Well: Rrt.. ft.
CIAq tit ler Recharge ClGimundwatcr Remedial ion 1)SANR1GRtVIL PACK Of aNMeabk1
WHOM TO MI4TPR14I. tMM.M-ENIrNTMVTHOn
°Aquifer Storage and Recovery ❑Salinitc Hamer 2 IL 14 h. FILTER SAND 4 2
°Aquifer Test ❑S omm:ucr Ihainagc h•
❑E'pcnmcntal Technology ❑Subsidence Coign!!
24.DRILLING LOG testate additional sheets if orceaan)
❑Geothermal(Closed Loopt ❑Tracts roots To aim-MPTtox i,,,I.r,intrdwew,n,ti4,w n t,far.Argon.err,tent
❑Geottrtnnal(Heating1Cooling Return l ❑O1het(explain under11 I Remaitsl 0 ft. 5 IL FILL SILT AND SAND
5 ft. 10 ft. WET SANDY SILT
4,Date Wrier,'Completed: 5-30-24 Wdl IDAECIT-NE-1IW01 10 ft. 14 ft WET SILTY SAND
5a.Well Location: ft ft•
i
USCG PFAS Site Inspection ft, ft. rx L-,.'fry n�1:::
Factlin.0ancrName Feedts,IDN(ifapplicabkt
R. ego JIJL 1 G 2024
1664 Weekaville Rd , Elizabeth City, NC, 27909 R. a--..
Pen sisal Address_Cis,.and Zip it.RIAIARILN IIR,.•r;A. r' ,-''!'*"4 UAt
Pasquotank BENTONITE SEAL 1 TO 2' Co11 'CAI,
�v
('ounh ParcclId,tint d.:atiunNo tPiNI
5h.!attitude and Longitude in degrees/minutes/seconds nr decimal diRrrmm: 22.Certification:
(d eel!field ',r ratio„g is stitiCkta)
N 1, Brian Ewing 6/21/2024
_. ,, II 011,,:d,t.a i.alrcwl.f Dew
6.Is late)the orbits): %Pertnanrnt or ❑Trmfoloran h, ,;;,,,.,,the,loom.!{tercel rr,1iO duo the wril(a!ear Sorrel rwnrtnuved in oorondmttc
with I54 NCAC 02C.0100 or 154 NCAC(IX.0200 Weil Caurlwewn Stootiordi oriel duo a
7.Ia Henri a repair to an exiatimg well: .....IYCN or Ise NO roc*o(thir re:ord hat;wen p,nro6•d ro the nvll owner
if;iris as a rrpalr,fill ant tnPMt n 41,Mutraw PV'n infVrn outni toil rcOwn t!4'IMRMrr of thi-
n-pair ruder 121 row ark,seilun,of on the&idiot this forts,. 23.Site diagram or additional well retails:
Vela may use the back of this page to provide additional well site details of well
S.Number of wells mmitrurted:.1, r�construction details. You n also attach additional pages if necessary.
For metope to(rerha i or Man-ire . •��rph Math o,Nv.T,,oh the moor congruent* ,.si u,r,
setbnir one form. 4l I RR1ITTa I INSTUCTIONS
9.Taal wdl de$h beim land surface: 14 (ft.) 24a. For All Wells: Submit this Tons within 10 doss of completion of well
F.,,'Mlieplr ails hut all drprhr if deferent lr.omnpfr)@NMY and 2fp 1tiYl constntctton to the fallowing•
10.Static water ksti tickle top of casing: (ft.t IKsisiun of Water Resources,Information Processing I nit.
insure lest r,,,h,,,r,,I'..:,, ,•• • 1617 Mail Service('cater,Rakish,N('276994617
Li.Rmrebak diameter 8.25" (in.) lib.for Injection W'e1Jl ONLY: In addition to sending the form to the address in
24a above. also submit a copy of this form within (0 dins of completion of Hell
12.Well were tetNm me(bod:BORED :oustnuliun to the following,
tic.auger.roan.cable.direct pink at.)
Din Winn of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 16.16 Nail Nen ice Center.Rakish.NC 21699-l636
IJt Yield(t9tnf l Method of test: 2k.For Water Supply X Injection Wells:
Also sUb111111 orta copy of this 'ono nilhm 'o days or completion of
IJb.Disinfection type: Amount: well commisconstructionu etion to the health dcpnnnnt of the courts where
eoastntcted
Form GW'-1 Nonh Carolmaa Depanmem of Ems mmmumKni aid Natural Resources-Dinnion of Water Retorts Rc,used August Hit 1