GW1-2021-00243_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
VINCE FEDERLE 14.WATER ZONES
Nell Contractor Name FROM TO DESCRIPTION
A - 3552 rt.
ft. I D.
NC Well Contractor Cenificadon Number 15.OUTER CASI Ifor multi-eased weus OR LINER ih livable
GEOLOGIC EXPLORATION iROxl TO DIAMETER THICKNESS MATERIAL
n. D. in.
Company Name
16.INNER CASING ORTUBING isothermal closed-too
2.Well Construction Permit H: FROM TO D,A , ER
THICKNESSI MATERIAL
l,vadapprrrahk oell mn.,n,nun.perm....,6.r. fll(-.Count' score. ra..anre,e,c-/ 0.0 t. 4.0 n 1.0 ' SCH 40 PVC
3.W'ell Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM 110 DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft- n, In,
4.0 14.0 1.0 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n n r
❑Industrial/Commercial ❑Residential Water Supply(shared) n.
18.GROUT
❑irrlatlon ❑Wells> 100,000 GPD FROM TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
'
Non-Water Supply Well: 0.0 n' 1.0 fit• eOsruRD BENToanE SLURRY
aflMonaming ❑Recovery fit. fit.
Injection Well:
h. fit.
GAquifer Recharge oGroundwater Remediation
19.SAND/GRAVEL PACK ifspot cable
El Aquifer Storage and Recover} ❑Saliniry Barrier FROM '10 MATERIAL fMPIA(EMF.,\T MEfHOD
❑Aquifri-Test ❑Stormwater Drainage 2.0 a 14.0 a- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. fit.
❑Geolhennal(Closed Loop) ❑Tracer 20.DRILLING LOGams, h additional sheen Uneressa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardnevs.>oiV.kD imi ern.
0.0 ft- 1.0 D• GRAVEL
4.Date Wells)Completed: 01/07/21 Well IDk PZ-2 1.0 D, 14.0 ft- GRAY CLAYEY SAND
Sa.Well Location:
fit. It.
INTERNATIONAL PAPER ft. A.
Facdu,0.ner Name Fbc9i,ID-tifapphiitble) n. ft.
1785 WEYERHAEUSER ROAD VANCEBORO 28586 ft. rt.
Physical Address,City,and Zip ft. ft
CRAVEN 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL- 1.0-2.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***PRE-PACK SCREEN...
(if.,])field,one Im/long is su Rciern) 22.Certification:
350 13' 38.39" N 770 06' 27.73" W
1/15/2021
6.Is(are)the well(s): OPermanent or D'Femporan Signature ofCemoicd Well Contractor Date
IT. .....m.on,loan.I a"h3"'In,d.a,,he yell/)urn fuere/"oo,runa/m aaomJnnce vulr
7.Is this a repair to an existing well: ❑Yes or MIND lSd.4'('d( 112('.0100 or l5,, A('d('02(' 0 100;Yell('on,vucrion SromloruS and rlmr it ror.
[l rhr.rs a rq+uv,fill uw k„mn,ued carranuv.a,....Jor..mmn arrd enrlum,he naavr J rho in do,record has heen prarnkd m the uell oum•r
reran under=21 remarks seenan or or.,he hock q/',his l rm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 11 You may use the back of this page to provide additional well construction info
construction,only l GW-I is needed- Indicate TOTAL NUMBER 9f Mflls't n (add'See Ovee in Remarks Box) You may also attach additional pages itnecessaA-.
drilled IMP: /i Ij
24.SUBMITTAL INS'fRC('I'IONS
9.Total well depth below land surface: 14.0 (fit)
/-b.....lople urlly ll.rl a//,kr,h,,ud�ren,(ornplu-3�00'and24000) Submit this GW-Iwithin 30 days of well completion per the following:
6.0 249. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
ll icon•./erd„nhore rasing urt
11.Borehole diameter: 8.0 (in.) 24b. For Infection Wells: Copy to DWR, Underground Injection Control (TUC)
Program, 1636 MSC,Raleigh,INC 27699-1636
12.Well construction method: AUGER
24c.For Water en al h and department Geothermal Return Wells Copy to the
I i.e.auger,rotary,cable,direct push,ism-) county environmental health department of the county Where installed
FOR WATER SUPPLY WELLS ONL\': 24d. For Water Wells producing over 100,000 GPD: Copy to DWR,CCPC'UA
13a.field(gpm) Method of test: Permit Program, 1611 MSC,Raleigh,NC 2 7699-1 6 1 1
13h.Disinfection type: :Amount:
Form GW-1 North Carolina Department of Emurmmenml Quality-Division of Water Resources Revised 6-6-201a