GW1-2021-00318_Well Construction - GW1_20210312

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
COREY FUTRAL FROM ERzONz"S
FROM TO DESCRIPTION
Well Contractor Name rL ft
4330-B rt ft.
NC Well Contractor Certification Numbers IINNER iaA5IN01tST(7BIt G o h IA0001
FROM I TO I DIAMETER THICKNESS I MATERIAL
CATLIN Engineers and Scientists 0 ft. 11 rt. 2 in. Sch.40 PVC
Company Name 6. UTFdiCCi1S11G form ti-�i"caa'�edls i#a ica e
N/A FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: rt. ft. DIAMETER
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 11 ft. 11 ft. 2 in. SIot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. rt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) v0GRDU'
FROM TO MATERIAL EMPLACEMENT N IETHOD&AMOUNT
❑Irrigation
Non-Water Supply Well:
®Monitoring ❑Recovery
n. ft.
Injection Well: ft. rL
❑Aquifer Recharge ❑Groundwater Remediation19SANDYGRAFTItPAGK'ifs e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stomnvater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 0 rt. 11 ft. Natural Backfill
20TDKWLIN:T.I s addiho sh rf,n a
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness soiUrock N size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 03/04/21 Well ID#: 234DPT-04 rt. rt. —
rt. rt. S �O
Sa.Well Location:
NCDOT-Geotechnical Engineering Unit Parcel#234 �-.No
Facility/Owner Name Facility ID#(if applicable) tr.
rt.
811 Old Cherry Point Rd.,New Bern,NC
Physical Address,City,and Zip ft. ft
21�REMAR' KS
CRAVEN
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lat/long is sufficient) Gti
35.083599 N -77.031232 W cJ 3/8/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ®Temporary By signing this farm,l hereby certifv that the well(s)was('were)constructed in accordance with
I SA NC:4C 02C.0100 or i5A MAC 02C.0200 Well Construction Standards and that a copy of
7.Is this a repair to an existing well: ❑Yes or ®No this record has been provided to the well owner.
if this is a repair,fill out known well construction information and explain the nature of
the repair under r21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,You
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 11 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths in different(example-3 200'and 2@100) construction to the following:
10.Static water level below top of casing: 4.5 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the
address in 24a above,also submit a copy of this form within 30 days of
12.Well construction method: DPT completion of well construction to the following:
(i.e.auger,rotaty,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection Wells:
Also submit one copy of this form within 30 days of completion of well
13b.Disinfection type: Amount: construction to the county health department of the county where constructed.
Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016