GW1-2021-00372_Well Construction - GW1_20211220

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Thomas Jason White FROM To DFSCRU TION
Well Contractor Name ft• ft.
ft. R.
3 3Z-A f
NC Well Contractor Certification Number 15.OUTER CASING ror:multl easeid wens OR:LINER If a"`livable. . '
. FROM. -TO DIAMETER .THICKNESS .. MATERGL
S&ME.Inc e. ,n
Company Name 16.INNER CASINGOR TUBING" eothermal;cl6sed-loop)
FROM TO DIAMETER THICKNESS. I MATERIAL
2.Well Construction Permit#: ���ft• �f► ,n SCh 40 PVC
List all applicable well permits(Le.County,State,Variance,Injection,etc.)
tt. R In.
3.Well Use(check well use): 17.SCREEN
. . FROM. 'TO .. DIAMETER SLOT SITE ' .THICKNESS MATERIAL..
Water Supply Well:
OAgricultural I IMunicipal/Public +pfL 2 iO .010 Sch 46 PVC
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply ft. in.
M. . g/ 8 PP Y) PP Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) I8.'GROUT'-
.
FROM- 'TO .MATERIAL EMPLACEMENT METHOD do AMOUNT
❑Irri lion 0rt
Non-Water Supply well: IV.>• . Grout Treinie.. .
.RMonitoring, ❑Recovery fi Bentonite Pour.
Injection Well:
13Aquifer Recharge ❑Groundwater Rernediation 19:SAND/GRAVED PACK- a 01leible
- k
FROM. TO. - . . MATERIAL. EMPLACEMENT METHOD
OAquifei'Storage and Recovery OSalinity Barrier L t. �� #2 Sand Pour
❑Aquifer Test ❑Stormwater Drainage It.
❑Experimental Technology ❑Subsidence Control
:20:DRILLING LOG'attach aadMoifal sheetd`,f.fi&essa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color tiardn sollfrocir Ww,
v a eta
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) b ft !' ,�--•;:: �+ �,
4.Date Well(s)Completed: Well ID# .
I" fL
58.Well Location:, fb ft
Dom'tar Plymouth
ft. ft.
Facility/Owner Namc ! Facility ID#(if applicable) ft. ft.
h
1375 NC-149 Plymouth NC n. ,t.
Physical Address,City,and Zip 21.REMARKS'
Washington
County parcel Wntification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 4je,11
22.Certification:
(if well field,one lat/long is sufficient)
35.858867 N -76.779011 W
Z . .
Siinattirc.0tCertifled'Well Contractor ..Date
&Is(are)the.well(s): OPermanent or ❑Temporary sl n this orm:There O ( )By gni g j by certify that the wells was we're constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C:0100 Well Construction Standards and that
7.Is this a repair to an existing well: ❑Yes or. Mo. copy of 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#21 remarks section or on the back of this form. 21 Site diagram or additional well details:
You may use the back of this page:to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages ifnecessary:
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surfacer. �`/ r (ft) 24a. For All Wells: Submit this form within 30 days of.completion of well
For multiple wells list all depths ifd fferent(example-3(a3200'and 2@100) construction to the following:
10.Static water level below top of casing:..e!" (ft.) Division of Water,Resources,Information.Processing Unit,
Ifwater level is above casing,use"+" 1611 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in.
Auger 24aabove,also submit a copy ofthis form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary;cable,direct pusti,etc.)
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-163.6
13s:Yield(gpm) Method of test 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 .days of completion of
136.Disinfection type: Amount: well constriction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013