GW1--06895_Well Construction - GW1_20231030

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells... •
1.Well Contractor Information:
S
William J. Miller F-RROM TERzo O IDESCRIPTION • •
Well Contractor Name ft. ft.
.2927A ft. R. ` ,
'•NC Well Contractor Certification Number 15.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO _ DIAMETER THICKNESS 'MATERIAL
CATLIN Engineers and Scientists .O•rt. 1.3 ft. ; 1. • in. Sch.40 • PVC
Company Name 16.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO • DIAMETER THICKNESS MATERIAL
•
2.Well Construction Permit#: N/Art. R. in.
List all applicable well permits(i.e.County State, Variance,Injection,etc.) - • , . . .
R. ft. , . in. .
3.Well Use(check_well use): 17.SCREEN
Water Supply Well: - FROM TO 'DIAMETER SLOT SIZE THICKNESS , MATERIAL . .
❑Agricultural 0 Municipal/Public. . 1.3 ft. 11.3 ft. 1 ..in. .Slot.010 SCh.40 . PVC •• -
❑Geothermal(Heating/Cooling Supply) . 0 Residential Water-Supply(single) :.!F ft. in.
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
O Irrigation • - •
NomWater Supply Well: ft. R.
IN Monitoring. . 0 Recovery 0-ft. 1 R.
• Injection Well: ' rt. ' ft. ..
' 0 Aquifer Recharge' 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑AquifeStorage and Recovery 0 Salinity Barrier '. FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer
❑Aquifer Test 0 Stormwater Drainage
1 ft: 12 ft. . Torpedo Sand Surface Pour
• • ❑Experimental Technology ❑Subsidence Control ft. Q. . ' • . - , •
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothermal(Closed Loop) , ❑Tracer FROM TO - -DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) R: ft.
4.Date Well(s)Completed: 09/26/23 Well ID#: SB06/TMW-6 rt. .
ft.
5a.Well Location:
R. R.
Geosyntec Ipk1
� �N
Facility/Owner Name Facility ID#(if applicable) ._
3648 S.Fields Street,Farmville,NC.27828 - - /� ' " t-,.,J,t'
Physical-Address,City,and Zip . R R OCT `"
•
• 21.REMARKS t) U Ill 2 2
J
PITT - .. . . ir. cr;-1 r,,
County Parcel Identification No.(PIN) ';•• t .X
5b.Latitude and Longitude in-degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient). ..
35.5931429017 N_-77.5994352425 w 10/18/2023"_
Signature of Certified Well Cont r • Date
6.Is'(are)the well(s): ❑Permanent . or ®Temporary By signing this form,I hereby certify that the well(s)was(were)consnmcted in accordance with
I5A NCAC 02C:0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of
7.Is this a repair.to an existing well: ❑Yes or ..®No ' this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of
the repair under#2I remarks section or on the back of this form. 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 one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .. 11.3 . (ft,) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple-wells list all depths in different(example-3 a 00'and 2@IO0) construction to the following:
10.Static water level below top of casing: 4 (g,) Division.of Water Resources,Information Processing Unit,
Ifuvater level is above casing,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 24a above,also submit a copy of this form within 30 days Of
12.Well construction method:_Power Probe completion•of well 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 Svpply&Injection Wells:
• Also submit brie copy of thisiform within 30•days of completion of well .
• . 13b.Disinfection type: • -- - Amount: _
construction to the county health department of the county where constructed:
Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

• •Geosyntec Consultants . Geosyntec°
Boring Log - .. consultants
j!s`I DRILLING CO.: . C AA-ksknSITE 66t7wct+ 5c7Y\ Borjn ID: S 0 C
DRILLER: Dj•1L Belle_( PROJECT NO.: GY(1 (D Sheet• l of •1
•
USCS/ •
Depth Time Lithology Log Rock Run Rec VOC Notes/Sample ID •
ft(his) Type (No.) ( ) (ppm)
.
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