GW1-2021-00496_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATERZONES
Jim Robertson
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4482
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ticable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rr. 15 ft. 2 in. SCh40 PVC
List all applicable well permits(i.e.C'ou aY,Stare,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft- 30 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 1 10 ft. Portland Cem Tremie
Non-Water Supply Well:
@Monitoring ❑Recovers- 10 f` 13 f` Bentonite Chi Tremie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL EMPLACEMENT METHOD
13 f` 30 f` #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. 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,girain size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well 2-17-21 MW-28s)Completed: Well ID#
5a.Well Location:
Pfizer Pharmaceutical ft. ft. YAR t
Facility/Owner Name Facility ID#(ifapplieable) ft. ft.
4285 N Wesleyan Blvd, Rocky Mount, NC 27804 ft. ft.
U vt i J
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 lat/long is sufficient)
36.035868 N -77.760929 W ��=„y� .2y3- A
Si ature of Certified Well Contractor Date
6.is(are)the well(s): [OPermanent or ❑Temporary 13v signing This forni, 1 herebv cerlift,that the well(s)was(mere)constructed in accordance
with 15A NCAC 02C.0100 or USA NCAC 02C.C1200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well corner.
1/this is a repair.fill out known well construction information and explain the nature of the
repair under-21 rentarks section or on the back ofthis jorm. 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.
Far multiple injection or non-water supply n'ells ONI Y wilt the same construction,You can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 24a. For All Wells: Submit this form within 30 days of completion of well
For nmhip/e me/lc list all depths ifdiJJereni(example-3@200'and 2 u 100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
U 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 coun where
constructed.
Form GW-I Nortlt Carolina Department otEnvironntent and Natural Resources-Division of Water Resources Revised August 2013