GW1--06322_Well Construction - GW1_20230927

WELL CONSTRUCTION RECORD For Internal Use ONLY I ,
This form can be used for single or multiple wells
1.Well Contractor Information: ,
-14.WWATERZONES • . . '
Austin Fowler FROM TO DESCRIPTION -
Well Contractor Name ft. ft.
4366A ft. ft I 1 .
NC Well Contractor Certification Number .15.'INNER CASING OR TUBING(eotliermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 10 ft. ;. 4 Sch.40 PVC
Company Name 16.OUTER CASING(for multi-cased wells)OR-LINER(if applicable) . .
FROM TO DIAMETER ' THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft. ft. F in.
List all applicable well permits(i.e.County,Stare, Variance,Injection,eta)
ft. ft 1' in.
3.Well Use(check well use): 1a:scREEN
Water Supply Well: FROM , TO DIAMETER- SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft. 20 ft. 4i iin. Slot.010 Sch.40 PVC
I
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. ( 'in.
❑Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT' ..FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0.5_11. 1 ft Portland Cement Surface Pour
Non-Water Supply Well:
0 Monitoring ®Recovery 1 ft. 9 it Bent.Pellets Surface Pour
Injection Well: ft ft.
0 Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) . .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROMTO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stornsater Drainage 9 ft 20 ft. I Torpedo Sand Surface Pour
0 Experimental Technology 0 Subsidence Control ft. ft.
20.DRILLING LOG(attach additional sheets if necessary).-.- - .
❑Geothermal(Closed Loop) 0 Tracer FROM TO DESCRIPTION(color.hardness,soil/rock type.grain size,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. I'
4.Date Well(s)Completed: 08/29/23 Well ID#: RWO2 ft rr. ��
n. ft. IV eD
5a.Well Location: �
NCDEQ - ft rt
Facility/Owner Name Facility ID#(if applicable) Ipa:c I!
id.r. y�r
125 US 13-17 South,Windsor,NC,Windsor,NC u $ V { y y�
Physical Address,City,and Zip ft. ft. i. •~�F®�+-.r
21.REMARKS:.. . - -
BERTIE iI SEP ► 7 2023 •
County Parcel Identification No.(PIN) - -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: V ' +
(if well field,one latllong is sufficient) 22.Certification: •'
35.980251 N -76.955909 w 9/29/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary 'By signing this form 1 hereby certify that the mell(s)was(were)constructed in accordance with
15A NC AC 02C.0100 or I5A NC'AC 02C.0200 Well Construction Standards and that a copy of
7.Is this a repair to an existing well: D Yes or l No this record has been provided to the well owner.
1f 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. 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 !i
can submit one form. SUBMITTAL INSTRUCTIONS
1
9.Total well depth below land surface: 20.0 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths in different(example-3@200'and 2@100') construction to the following:f
10.Static water level below top of casing: 13.7 (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: 10.25 (in.) 24b.For Injection 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: H.S.AUGERS completion of well 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 Servi ie Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Slimly&Injection Wells:
Also submit one copy of this forin within 30 days of completion of well
construction to the county health!department of the county where constructed.
13b.Disinfection type: Amount:
Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016