GW1-2021-00499_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Jim Robertson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. Wet
4482 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER rf a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR.. BING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 fr. 15 fr. 2 in. sch40 PVC
List all applicable trell permits(i.e.Coun(v,State,Variance.Injection,etc.)
fr. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 f" 30 ft- 2 "' 1 .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply f. ft. in.(sin le)❑Industrial/Commercial El Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fr. 10 fi- Portland Cem Tremie
Non-Water Supply Well:
10 ft- 13 ft- Bentonite Chi Tremie
ZMoni[orins ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 13 fr' 30 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) R. ft.
4.Date Well(s)Completed: 2-9-21 Well 1D# MW-25
ft. ft.
5a.Well Location: M s�
ft. ft. 1
Pfizer Pharmaceutical
Facility/Owner Name Facility ID4(ifapplicable) - _ •• ''°;nrnZn; , t.at�,
ft. ft. f;) C+nn
4285 N Wesleyan Blvd, Rocky Mount, NC 27804 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Nash 8 FMC Pad
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one[at/long is sufficient)
36.035626 N -77.762456 N; a
Sit ture of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary Hy.igning dais*orm,/hereby certify that the well(s)was(were)constructed in accordance
wah I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Fes or 0 No opt,q1 this record has been provided to the well owner.
!/'this is a repair,Jill our known well construction inJbrmation and explain the nature q1 the
repair under=21 remarks.section or on the back ofthis farm. 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 oneJorin. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths#*different(example-d a 200'and 2 a 100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use'•- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
8 1/4 HSA 24aabove. also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 m Method of test: 24c.For water Supply&Injection Wells:
(gP ) WAlso 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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013