GW1--02092_Well Construction - GW1_20240405

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Austin Fowler FROM TO DESCRIPTION
Well Contractor Name ft. rt. j
4366A ft. ft.
NC Well Contractor Certification Number ,'15:"INIER3i�i2 it713TNG'#e6sherarat closed4ouu . .. .
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 3.44 ft. ,,, 1 in. Sch.40 PVC
Company Name Aft':'OUTER LASING#rnr.multt-cnse t welts)f)fR LINERRtff arinticabie)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft. rt. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
f?c SCREEN i '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3.44 ft. 13.44 ft. 1 ,in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial U Residential Water Supply(shared) t&GROTt• '` - - - t
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNr
0 Irrigation
Non-Water Supply Well: ft. ft.
®Monitoring 0 Recovery ft. ft.
Injection Well: ft. it.
❑Aquifer Recharge 0 Groundwater Remediation ID SAND/Gt AVEL PACK(Itiafticablel '
0 Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT
METHOD
ft. ft. Surface Pour
❑Aquifer Test 0 Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 0 ft. 16 ft.
'1.0.iiJkILLINGtOGfntfti&itldiftiftintsheeis ifnecessar + .
❑Geothermal(Closed Loop) 0Tracer
FROM TO DESCRIPTION(color hardness,soil/rock type gain size.etc 1
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 12/01/23 Well ID#: P4-TW43 ; ti -I,..2 n- /t.}y ^^.1 ft. S O
5a.Well Location: ft+ 171. ft �dq ��
A 'R it t.u��r Pk'
�`
R. ft.
PIE-PS '-- P,--.,: t.,Y
IA Facility/Owner Name Facility ID#(if applicable)�� .... Lib,dl�1 J,J
- pik,
ft.
PIT 4,Havelock,NC 28532
Physical Address,City,and Zip ft. ft
CRAVEN
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)
34.90837806 N -76.88928499 w 1/22/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 0 Permanent or ®Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
I SA 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 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 SUBMITTAL INSTRUCTIONS
can submit one form.
9.Total well depth below land surface: 13.4 (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@1002 construction to the following:
10.Static water level below top of casing: 11.5 (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.) I
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&Injection Wells:
Also submit one copy of this form within 30 days of completion of well
13b.Disinfection type: Amount: construction to the county health department of the county where constructed.
Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-201.6