GW1--02089_Well Construction - GW1_20240405

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information: � '
§I*OATektai;Zat:NMNNBRNEMISag:MMRPSIRMMpgggtzgmmgnMMW
William J. Miller FROM TO DESCRIPTION
Well Contractor Name ft. ft. 1
2927A ft. R. 1 .
NC Well Contractor Certification Number 'is INNF.tMASNG OW,T TBINGfi�eotheiiiiit ciosed4nep} . ..
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 2 rt. 1 in. Sch.40 PVC
Company Name P 1 OUT CASING(for mutti^cused*yells)OR LINER of§irititicstble)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. R. in.
3.Well Use(check well use): i?_Stlttt6N `^ ,-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural 0 Municipal/Public 2 ft. 12 ft. 1 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) R. R. in.
0 Industrial/Commercial 0 Residential Water Supply(shared)
I&tittit/'1:'b
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 Irrigation
Non-Water Supply Well: ft. R.
ft.
N Monitoring ❑Recovery
R.
Injection Well: R. ft.
❑Aquifer Recharge 0 Groundwater Remediation 19!SANiifGR tW PACK tff atititicabiel ••-
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
R. ft. Surface Pour
0 Aquifer Test ❑Stormwater Drainage
❑Experimental Technology 0 Subsidence Control 0 R. 12 R
26.Blittt NGLCate(attachadditionatstiee`teiifneeessatY3 ,.. ,t,: _.
❑Geothermal(Closed Loop) 0 Tracer FROM TO DESCRIPTION(color.hardness soil/rock type.Brain size.etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ft. R.
4.Date Well(s)Completed: 11/28/23 Well ID#: P4-TW26 rt. it. ��-
R. ft. eo
5a.Well Location: �� —
rt. it'll ,
Facility/Owner Name Facility ID#(if applicable) ft
�. 4., 'v ` b t„f 1:::''''d
ft. P m.
PIT 4,Havelock,NC 28532 ft. ft Afil- 0 i" [UL4
Physical Address,City,and Zip -2L't3Ei,1iAtik ,.,,,
CRAVEN 111 -. ti ,i 7« is vrtA
nUlt't:'tr1tz
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
34.90897654 N -76.89023757 w ----'''`�"' ".. 1/22/2024
Signature of Certified Well Conttaeto' Date
6.Is(are)the well(s): CI Permanent or ®Temporary By signing this form,I hereby certify that the well(%)was(were)constructed in accordance with
. I SA NCAC 02C.0100 or I SA 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 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
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12.0 (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@1009 construction to the following:
10.Static water level below top of casing: 11.03 (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: 2 (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: DPT 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 Svpply&Injection Wells:
Also submit one copy of this form 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