GW1--06323_Well Construction - GW1_20230927

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i WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells .
1.Well Contractor Information: , 1
14.WATER ZONES it i
Austin Fowler FROM - TO DESCRIPTION
Well Contractor Name ft. rt. f
4366A R• ft. 1
NC Well Contractor Certification Number 15.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 rt. 9 ft. r 4 in. 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. fL in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc) -
ft. ft. in.
3.Well Use(check well use): 17.SCREEN-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
• ❑Agricultural ❑Municipal/Public 9 rt. 19 ft. 41 ;in. Slot.010 Sch.40 PVC
o Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. 1 'in.
ElIndustrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL En PLACEMENT METHOD&AMOUNT
❑Irrigation 0.5 ft. 1 rt. Portland Cement Surface Pour
Non-Water Supply Well:
❑Monitoring ®Recovery 1 rt. 8 ft. Bent.Pellets Surface Pour
Injection Well: rt. ft.
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) '
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier
8 it 20 ft. • Torpedo Sand Surface Pour
❑Aquifer Test 0 Stommvater Drainage
❑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.soiFrock type.Twain size,etc.)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. rL
n. ft. ' le
4.Date Well(s)Completed: 08/29123_ Well ID#: RW01 ;� ell0
ft. ft. ��
5a.Well Location:
ft. ft. csic
NCDEQ ft
Facility/Owner Name Facility ID#(if applicable) Pk.11:.'
ft• w••1 rl" F'9, r q4.ra ynr..
125 US 13-17 South,Windsor,NC,Windsor,NC ft. ft. s 6 E.:k-ar V PL*,
Physical Address,City,and Zip
21.REMARKS
BERTIE SEP d 7 ZUZ3
County Parcel Identification No.(PIN) • •
lrf.7-7: .':1!".7 Pr^ tjr,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: •
22.Certification: ' + ,t`j0
(if well field,one lat/long is sufficient) ,
35.980273 N -76.955983 w � � �% � -� 9/29/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary - Br.signing this form,I hereby certi•/v that the wells)was(were)constructed in accordance with
15A NCAC 02C.0100 or i5A NCAC 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 tinder k2l 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
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 19.0 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For maltiple wells list all depths in different(example-30200'and 2@I00') construction to the following:I
10.Static water level below top of casing: 15.8 (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.anger,mica)),cable,direct push,etc.) Division of Water Resources,.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service1Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Svpply&Injection Wells:
Also submit one copy of this form within 30 days of completion of well
13b.Disinfection type: Amount: construction to the county her Ith department of the county where constructed.
I
Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016
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