GW1--02098_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:
Austin Fowler FROM _ TO DESCRIPTION
Well Contractor Name ft. ft.
4366A ft. ft.
NC Well Contractor Certification Number ..T5 INI EREAr'INGil3t'1'1 T14+7x(aothorinalclosed400pj
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 5 rt. 1 1 in. Sch.40 PVC
Company Name `t6 OUTER ASII 'iraEr+rolrvacd 6101t•tiNtit£dfatintieabite") `:
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. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 15 ft. 1 in. Slot.010 SCh.40 PVC
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft• ft• in.
0 Industrial/Commercial 0 Residential Water Supply(shared) &,GRCif "' ' "`'
FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
0 Irrigation
ft
Non-Water Supply Well: ft.
IR Monitoring ❑Recovery ft• ft.
Injection Well: ft. ft.
0 Aquifer Recharge 0 Groundwater Remediation ..ittSANAIGRMWC.PACkfiriipplicabte? _; .. :n"' -.
0 Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test 0 Stormwater Drainage ft. ft. Surface Pour
0 Experimental Technology 0 Subsidence Control 0 ft. 16 ft.
28.THUTLLIN(LOG(utfach.attdttiosal shells if necessarst} ,a
0 Geothermal(Closed Loop) 0 Tracer FROM TO DESCRIPTION(color,hardness.soil/rock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ft. ft. 1
4.Date Well(s)Completed: 11/30/23 Well ID#: P4-TW38 ft. ft. see_
ft. ft. es)
5a.Well Location:
ft. ft. �G", 'T r --.,. . F _ 7,''�
PIE-PS •k. \,..L.►, V l...•a..,
Facility/Owner Name Facility ID#(if applicable) ft. P:11.
ft. APR 0 5 2024
PIT 4,Havelock,NC 28532
ft. ft.Physical Address,City,and Zip
CRAVEN �;'. ,'�,v,..
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) � <
34.90799365 N -76.88964722 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
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 we//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: 15.0 (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:
10.Static water level below top of casing: 10.75 (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
I
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