GW1-2021-00508_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Jim Robertson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. Wet
4482 ft. 13.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
Compam Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft, 15 ft- 2 in. sch40 PVC
List all applicable u,e//permits(i.e.County,Slate,Variance.Injection,etc-.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft, 30 ft 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ts.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 10 ft- Portland Cem Tremie
Non-Water Supply Well:
0 Mon itori ng ❑Recovery
10 f` 13 f` Bentonite Chi Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑S[ormwater Drainage 13 ft 30 f`• #1 Sand Tremie
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#21 Remarks) ft. ft.
2-10-21 MW-31 ft. ft.
4.Date Well(s)Completed: Well ID# a Y
5a.Well Location: ft. ft.
Pfizer Pharmaceutical
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. ' c� %1'•-` t-'t It
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 ladlong is sufficient)
36.032759 N -77.764662 N; aA-e&A-T
Sign ure of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary g g 1 1 (J ( )
Hv.ct nin dtis arm, I hereby ecru v that the well s trar were constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 6Vell Construction Standards and than a
7.Is this a repair to an existing well: ❑Yes or 0 No copy q/'this record has been provided to the well owner.
I jthis is a repair,Jill out known well construction in/ormation and explain the nature o/'the
repair render 21 remarks section or on the back q/7his jorm. 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 tre/!s ONLY wah the same construction,you can
submit one 1hrm. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 24a. For All Wells: Submit this form within 30 days of completion of well
Far mu/riple welts list a/I depths ift4ljerent(example-3@200'and 2«100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
/J water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Infection Wells ONLY: 1n 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 1%1ail 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
13b.Disinfection type: Amount: well construction to the county health department of the cou ty where
constructed.
Form GW-I North Carolina Department of'Environment and Natural Resources-Division of Water Resources Revised August 2013