GW1--06101_Well Construction - GW1_20241014

WELL CONSTRUCTION RECORD For Internal Use ONLY: •
This form can be used for single or multiple wells
1.Well Contractor Information:
Todd Muench 14.WATER ZONES , ' --'4. . f. .
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I I
3371 ft. ft. I I
NC Well Contractor Certification Number 15.OUTER CASING-(for multi-cased'wells)OR LINER(if ap licable) '
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. l ' in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft. 2 in. sch40 pvc
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/Public5 ft. 15 ft. 2 i"' .010 sch40 pvc
['Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. `p• .
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM To.
O MATERIAL EMPLACEMENT METHOD&AMOUNT
['Irrigation 1 ft• 2,5 ft- Bentonite Chil Pour
Non-Water Supply Well: - -
ft. ft.
OMonitoring , ❑Recovery
Injection Well: ft. ft. i'
❑Aquifer Recharge ['Groundwater Remediation .19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
['Aquifer Storage and Recovery ❑Salinity Barrier
2.5 ft. 15 ft. #1 Sand Tremie
['Aquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology ['Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ['Other(explain under 421 Remarks) ft. ft.
ft. ft. a •,,,., S,.-'ii...,, , t.,,,4 it
4.Date Well(s)Completed: 9-9-24 Well ID#
ft. ft. O C T 1 4 2024
5a.Well Location: ft. ft.
USCG ft. ft. iG. :,,,,.. }'-:. r ":;
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1664 Weeksville Road, Elizabeth City, 27909 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Pasquotank 8"FMC
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)
36.26374 N -76.17584 �, /&-cid�GQ,� 9/24/24
Signature of Certified Well Contractor' Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo copy of 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#2/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 INSTUCTIONS
9.Total well depth below land surface: 15 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@/00') construction to the following:
i
10.Static water level below top of casing: unknown (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: 8 (in.) 24b.For Infection 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 completion of well
12.Well construction method: HSA construction to the following: l'
(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,I Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: .
'24c.For Water Supply&Injectionl Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: - well construction to the county health department of the county where
constructed.
I'
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013