GW1--06051_Well Construction - GW1_20241011

WELL CONSTRUCTION•RECORD \
For
This form can be used for single or oodtipk wells � I
1,Well Caniractar Information: I -
:til A2ER ZONES- i
Tyler Brown . . FROM ' 10 I ImseitIPriO%
• Will t;ontni dor.Namc
R. R.
4625• It. ff. I. !
-
NC Well Contractor Certification Nun er .t5:OUTER CASiNG.troy multi ctiscd ncflsl OR-LONER(heap Aeabl&-
FROM I-TO DIAMKTER-1 .THICKNESS, MATERIAL
SAEDACCO • .ft. i. ft.. i ie.
Conrp:ug•KaniV I6.JINNER'CASiNG OR TUBING frotberreal clusedaoop):;..'-- '
•-PROM • TO• _DIAMETER THICKNESS MATETUAL •
2.Well Construction Pcrtnit R: 0 'f. 5 it,' 2 !" 'SCH-40 'PVC
List till at>gicitble well primirs,(i_c.County.State,Varian-ea&lean t Kr,.) - - - _ - -
.0. • R, • in.'
3.Welt Ilse(checicwdl nsc). t7:SCREEN •
•
Water Supply Well: .__._ • - FROM. TO DIAMETER •SLOT SIZE III ICHRISS i MATERIAL. •
ClAgdcultutal LMunicipaliPlblic 5- ft. 15 R. 2 is 010 SCH-40 I PVC
. _ DGeatlietrnal(HeatingCCooting Supply) °Residential Water Supply(single) it. I . ft. iI . in I
• l l udnstriaUCoRuiterciai DRcsidcntial Water Supply(shared) 3F FROM
WIlT"To.. -MATERIAL EMPLACEMENTMEl11OR SASIOINT
°Irrigation • ' . .' 0 ' ft.. '3 " 11. Portland Pour
'Non-Water Supply Well .
WMonitorini • ARecovery V
Injection:Wetl: R- - n. . •
ClA+111ifer Recharge - ❑Grounditaicr Rclncdialion- I9.SAND/GRAVEL PACK(if ajgitieabk)' :. . - . "- ' --
PROM : _1 10' - I .IIATERLA1. t IPIAC MENT MFTNOn_
l7Agnifcr Storage and Rccotrry °Salinity aarjicr . 4 ft.• 15 R. I Sand 1 - 2
• Aquifer Test ASlormt ucr Drtinag
. .rt., ft. . ,,• .
DE?giecimcntal Tccfinotog ❑Subsidence Caidrol - --
-1UIDRiLLINGLOG(anach additional dwelt(ifrleccssanl -
ClOeottiennal(Clusetl Loop) . °Tracer. - ,FROM 10 . • DESCRIPtION lcobr.haroneri;folni ekispe.prtin rmrridy)',
°Geothermal(HeacinglCooling Return) dotter(explain nulder621 Remadi5) • eft- • R. i,
ft: ft:
• 4.Date Wep(s)Completed:'9/10/24 Well IDfMMW-1
R. ft..
55a.Weil Laeatuni7 iL 1 ft.:. E •,, ti.. t ,. r . a`.
•
QA•h lb..�;,. .,n >! Via., ,.t`
•
Bridgers Food Store "ft. - ft.
FacRity,'Oiencr.Namc Facility ION(if applicable) O. ft..; ��7�!1
302 S. Main St., Princeville,.NC, 27886 . ,ft. ft.- lriE,.
PlryliealAddress•City.and ZIp =xt.REi►tARl:s . , v • .
Edgecombe, • Bentonite seal from 3-4';
County P rcelliktilitie.1ii.nNo.(PIN)
5b.1:iuitiide and is ngimdein dcgrees/minutcslscconds or decimal degrees: 22,Certification:..
Orwell field,one I.ittlo it srdlickmil) j,
• N • W �` 9/26/2024
• Sigrnlri:.orCcitifred WellCowxter I' Duc
• 6.'slate)the svell(s):.xPermatient .or °Temporary By signurg thus fora,I hcrehy certify that the wigs)Win(Kerr)run_r nuie1 LT actonlmtce
• with l5t NC tC Inc.0100 or 15A NGtC;02C,0200 Welt Coustracriwr Standards mid slam a
7.Is tills a repair toanexisting,sicili °Yes or ®Nn nce- of this record hostr rh nproiikrtlrorIn711oinn-r, '
If rltfsli a repolr.Jill an known Will eorumralon informrrrion rout r.vpiaht the inarare of the
repair under All remarks3rctian nr on the bock of trio 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.Numberof Wells constructed: 1 • • caoustrnctiou details. You may also attach additional pages if necessaty.
For nulriple lrrfecitou Or owl-yoke suppli•wells ONLY Writ'rile same consrruetion,you echo
submit one form. . SITBMITTALINST€1CTTONS j
9.Total well depth beioww laud surface. 15 ' (ft.) 21a. Far All Wells:. Submit Ibis forin within 30 days of completion of welt
For nutlrlpleireflrrlisra(lJrprhiifri ireur(cxmrpfrl@200'anrl2@ilk+) construction to the following: •• i
10.Static water level belriw top of easing: • . ((1,) Diyiiiion of Water Resources,Itiformntion Processing Unit,
if Wilier hie)Is here casfai:user"+" • . I617 Mail Service Center,llalcig)i?C 27692-I417
11.Borehole diameter.8.25" , (in.) 21b.Tortnlectinrl Wells ONLY: in addition to sending the form to the address in
24aabove.also submit a copy of this:form within 30 days-of.completion.of well
12.Well construction method:HSA cotist:ut lon to the following:• 1' •
tic.anger rotary.cable direct gash.etc.) !
'Division of Water Resources,Underground Injection Control Program;
FOR WATER SUPPLY WELLS ONLY: 1636 gait Senice Center,Raleigh,NC 27699.1636
13a ti icld(>;pm) Method of test: 24e.For Water Supply&injcctioni�Vclls:
Also submit one copy of this fomi Within 30 days of completion.of
13b.Disinfection type: Amount: • well construction to the county health;department or the.county.whcrc
constructed. I
Fans GW-t NorthCarolina lkpai:rent of Erwimiun,-and Natural Resources—Disi;ionof WaterReaatIrcr5 Revised Aulust20I3
I