GW1--06900_Well Construction - GW1_20231030

WELL CONSTRUCTION RECORD• •: For Internal Use ONLY: i '
This form can be used for single or multiple wells .1 . .
. 1.Well Contractor Information: •
.. • 14.WATER ZONES
William'J. Miller -'_ • FROM • • TO DESCRIPTION •
• Well Contractor Name . . - :ft..- R. I ' ' .
2927A ft. :.R 1 r .
.
•
•
NC,Well Contractor Certification Number - 15.INNER CASING OR TUBING(geothermal closed-loop)
• FROM - . ::TO DIAMETER ' 1 THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 rt.: 2 R. ; ' 1: ..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.. R. in. .. ..
. List all applicable well permits(i.e.'County State, Variance,Injection,'etc.)..
• .. l. .. .. 'ft. It. in. " .:- . .
• .,. 3.Well Use(check well use): • - - ' •.
17.SCREEN .
Water Supply Well:
FROM TO V DIAMETER . SLOT SIZE. :THICKNESS MATERIAL
❑Agricultural • ' ❑Municipal/Public, - ... 2 ft•. 12 ft. ' • 1 in. Slot.010 Sch.40, .. PVC
•
. ❑GeothermaF(Heating/Cooling Supply) . ❑Residential Water::Supply(single) :-R. , R. in. • ,,_ , ,
E IndustriaUCommercial' ' 0 Residential Water Supply(shared). 18.GROUT
• FROM TO • MATERIAL EMPLACEMENT METHOD&AMOUNT
•'• :.: ❑Irrigation :.:. : -
NomWater'Supply Well: . .. --
El Monitoring- . . - ❑Recovery .. ' - • V 0 ft. . . 1 ft.
••
Injection t. . t. -
, . 0 Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ' . -' ❑SalinityHairier : FROM TO MATERIAL EMPLACEMENCMERTOD'
❑Aquifer Test: -•- V• . - '❑Stormwater Drainage
.1'a; 12 R. i Torpedo Sand Surface Pour, -
❑Experimental Technology . 0 Subsidence.Control •
.
' 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Lbop) ❑Tracer --' : , ' FROM TO • •DESCRIPTION(color,hardness,soil/rock type,Brain size,etc.) •
❑Geothermal(Heating/Cooling Return) : V ❑Other(explain under#21.Remarks) R: R. .
4
:.: 4.Date Well(s)Completed: 09/26/23 Well ID#i SB01/TMW-1 :. ' ft' ' - . • ft' Sfoofio_-:.. •- 0
. ,
ft .• :.:.
• • V V'5a.Well Location:
•• Geosvntec :. .•• .
. ... ' .Facility/Owner Name -, . .FacilityID#(if applicable):' .pk� F
ft. • ''a;6,;.t `c;-''; ', Yr 1 . .
3648 S:Fields Street,Farmville,NC 27828 ' • V .°
. ft.:: ft.
Physical Address,City,and Zip . . 21.REMARKS u C IT
t3 U /I I
.. .. PITT '
County Parcel Identification No.(PIN) ln" "'"'' ' '"`�'. 1�:,:i
5b.Latitude and Longitude in degrees/minutes/seconds Or'deciinal degrees: 22.Certification:
(if well field,one lat/long is sufficient).'.
35.5933650792' ' N -77.59'96399755 ••vv . .: •" .• •:..','• • 10/18/2023':•..
. ' V - Signature of Certified Well Cont ' r ' Date
6.Is(are)the weil(s): ❑Permanent - :or ®Temporary By signing:this form,I hereby certify that the well(s)was(were)constructed in accordance with
15A NCAC 02C:0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of
-' .. . . 7.Is this a repair_toan existing well: 0 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#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 nntltiple injection or non-water supply wells ONLY with the same construction,you , ' ' ' ' ' '' '
SUBMITTAL INSTRUCTIONS
can submit one form:
9.Total well depth below land surface: • • -_12.0 . .(g,) • 24a.For All Wells: Submit this form within.30 days of completion of well - ••
• For nidtiple:wells list all depths in different(example-3@200'and 2@1002: construction to the following: ' ' '
•• 10.Static water level below top of casing: 4 (g) ; Division of WaterResources,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 Iniection'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: Power Probe - .. 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 Service.Center,Raleigh,NC 27699-1636
13a.Yield(gpm).. - Method of test: . • ' .
•
24c.-For Water Supply&Infection Wells:
Also Submit one copy of this form within 30 days of completion of Well
13b.Disinfection type:, - Amount: c struction toty halt department cou tywhere constructed:onthe coup h de a nt of the n ructed"
I- -
• Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources:.Division of Water Resources... Revised 2-22-2016

Geosyntec Consultants.
Geosyntec
Boring Log consultants.
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DRILLING METHOD: DATE STARTED: Borehole Location Sketch Map/Reference
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, . Lithology Log_.
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