GW1-2021-00509_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:
14.WATERZONES
Jim Robertson
FROM TO DESCRIPTION
Well Contractor Name ft. ft. wet
4482 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-eased wells OR LINER if a Iicable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Compam Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft- 2 t"' 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 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft' 25 ft- 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling/Coolin Supply) ❑Residential Water Su Iv sin le ft. ft. in.
( g g PP Y PP ( g )
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 5 ft. Portland Cem Tremie
Non-Water Supply Well:
ZMonitorine � ❑Recover'
5 ft. 8 ft. Bentonite Chil Tremie
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
8 ft' 25 fr• #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attaeh additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color•hardness,soil/rock e,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 2-1 1-21 Well ID# MW-33 ft. ft.
5a.Well Location: ft. ft. MAIR -
2021
Pfizer Pharmaceutical ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. ft.
4285 N Wesleyan Blvd, Rocky Mount, NC 27804 ft. ft. "; l r;
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)
36.034293 N -77.764376 W ILI �1�� �3
Sigr ture ofCertr re�I Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary Hy signing this form,I hereby certify that the ire//(s)ryas(u ere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy oJ7his record has been prorided to the well owner.
ll'this is a repair,Jill out known well construction information and erplain the nature q1 the
repair under:-21 remarks.section or an the hack oJ'dris/brm. 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 necessan.
For multiple o jection or non-water supply we//s ONLY with the same construction,you can
suhntit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 24a. For All Wells: Submit this form within 30 days of completion of well
For nudliple wells list all depths ifth&reni(example-3 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,
1/'water level it above caring,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
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(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 county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013