GW1-2021-00500_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Jim Robertson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. Wet
4482
NC Well Contractor Certification Number 15.OUTER CASING for mtilh-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. C. I ft. I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 15 ft. 2 in. sch40 PVC
List all applicable well permits(i.e.(bunv.State, Variance,Mjeccion,etc.)
ft. ft, in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 "' 30 ft' 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply f. ft. in.
(sin le)❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 10 ft. Portland Cem Tremie
Non-Water Supply Well:
EMonitoring ❑Recovery 10 ft 13 ft Bentonite Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
13 ft' 30 ft #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage rt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
2-9-21 MW-26 - Qy, .�� .z<:
4.Date Well(s)Completed: Well ID# w -
ft. ft.
5a.Well Location: ft. ft. MAR 15 20ZI
Pfizer Pharmaceutical ft. ft.
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. Ira :ii l i;'3Rc�e;t ,'j""' •,
4285 N Wesleyan Blvd, Rocky Mount, NC 27804
Physical Address,City,and Zip 21.REMARKS
Nash 8 FMC Pad
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one tat/long is sufficient)
36.036189 N -77.761615 w
nature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this 1brin,I herehv cerlifv that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construciion Standards and that a
7.Is this a repair to an existing well: ❑Yes or K Nu copy of this retard has been prorided to the net/owner.
/(this is a repair,fill out known well construction information and explain the nature of the
repair under 21 remarks section or on the back q/'/hiss/brm. 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-timer supply wells ON/Y widu the same construction,you can
submit one farm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 (ft.) 24a• For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdii fereni(example-3 a200'and 2@100') construction to the followin4:
10.Static water level below top of casing: (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
8 1/4 HSA 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,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
m 13a.Yield
(gp ) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Depannicnt ot'Environnient and Natural Resources—Division of Water Resources Revised August 2013