GW1--06644_Well Construction - GW1_20241108

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l Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Brian James Bellis 14.WATERZONES ,
FROM TO DESCRIPTION!
Well Contractor Name - 1
NCWC 3510-A 8.5 ft >13.5 ft• Water table:reached while removing USTs
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
WithersRavenel, Inc. FROM TO - DIAMETER THICKNESS 1 MATERIAL
ft. ft. j in:
Company Name
Not Applicable 16.INNER CASING OR TUBING(geothermal closed-loop) ,
2.Well Construction Permit if: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(I/C County,State,Variance,etc.) 0 ft. 8.0 ft. 2 i in' Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 8.0 ft 13.0 ft• 2 in' 10 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - - - 0 ft 2.0 ft• Concrete Hand mix and pour
X Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL . EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage 8.0 ft• 13.0 ft• Filter sand Pre-packed screen
Experimental Technology OSubsidence Control ft. ft. i
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
0 ft. 9.0 ft. Clean!fill soils from off-site source
4.Date Well(s)Completed:10-9-24 Well ID#MW-1 9.0 ft. 13.5 ft. Tan brown silty sand typical of coastal plain
5a.Well Location: ft. ft.
Well's General Merchandise 0-0-22447 ft. ft. s! ‘,.,r.z,,,..,1•_: 1' G.>,a...a
Facility/Owner Name Facility ID#(if applicable) ft. ft. N 0 V 0 8 2024
3300 Benvenue Rd, Rocky Mount 27804 ft. ft.
Physical Address,City,and Zip ft. ft. II'• °" 'ri • `17 "d';
`.,
Nash 384200406393 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.998555 N -77.834201 W e-"-tG2,- 10-31-24
6.Is(are)the well(s) Permanent or Temporary Si re of Cert ell Contractor Date
_ By signing this form,1 hereby_cerrify that the-wells)was(were)constructed in accordance - _
7.Is this a repair to an existing well: cYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under-21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also'attach additional pages if necessary.
I
drilled: NA
SUBMITTAL INSTRUCTIONS;
9.Total well depth below land surface: 13.5 ft.
P ( ) 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@100) construction to the following: i
10.Static water level below top of casing:-8.5 (ft.) Division of Water Resources,Information Processing Unit,
limner level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3 (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
Manually while backfilling UST pit above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: l '
(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: In addition to sending the form to
the address(es) above, also submit)one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016