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Home My WebLink AboutGW1--06897_Well Construction - GW1_20231030 WELL CONSTRUCTION RECORD. For Internal Use ONLY: • This form can be used for single or multiple wells 1.Well Contractor I,nformation: . . William J. Miller FROM WATER ZONES TO _ DESCRIPTION - Well Contractor Name ft. ft. I . .2927A . ft. ft. I . NC Well Contractor Certification Number 15.INNER CASING OR TUBING(geothermal closed-loop) FROM •.TO DIAMETER : • THICKNESS MATERIAL CATLIN Engineers and•Scientists . . 0,f. 1.5 ft. 1 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/A rt. ft. in. List all applicable well permits(i.e.County,State, Variance,Injection,-etc.) - .. in. 3.Well Use(check well use): 17.SCREEN • Water Supply Well: FROM TO DIAMETER SLOT SIZE ' THICICNESS' MATERIAL . ' ❑Agricultural ❑Municipal/Public .1.5 ft, 11.5 ft. 11 in. Slot.010' Sch:40 . PVC ❑Geothermal(Heating/Cooling Supply) _ 0 Residential Water-Supply(single) rt. R. in. • 0 IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT FROM TO MATERIAL EMPLACEMENT METHOD&AIv1OUNr •• ❑Irrigation Non-Water.Supply Well: rt. lt. ElMonitoring 0 Recovery 0 ft. 1 ft. . Injection Well: rt. •a. : . - ❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) • ❑Aquifer Storage and Recovery 0 Salinity Barrier. FROM TO MATERIALEMPLACEMENCMETI{oD ' . ❑Aquifer Test ❑Stormwater Drainage 1 7t 12 ft. Torpedo Sand Surface Pouf. ❑Experimental Technology ' CI Subsidence Control ft R. 20.DRILLING LOG(attach additional sheets if necessary) ❑Geothermal(Closed Loop) ❑Tracer FROM TO •DESCRIPTION(color,hardness;soil/rock type.Bain size,etc.) • ❑Geothermal(Heating/Cooling Rettirn) ' 0 Other(explain under#21 Remarks) ft. . ' ft. ' 4.Date Well(s)Completed: 09/26/23 Well ID#: SB04/TMW-4 �� . ft. .R. �O 5a.Well Location: � ' R. ft. Geosvntec .ItI� . i A./ f l r Facility/Owner Name •-.Facility ID#(if applicable) N r r - .,t ft. ,-_ fir! 3 ,9 7n 71 . . • 3648 S.Fields Street,Farmvilie,NC 27828 -• 4- �i - . .: ft.• ft. . Physical Address,City,and Zip . • 21.REMARKS PITT ' ;iv,. 0,0 County Parcel Identification No.(P;IN) •' . 5b.Latitude and Longitude in degrees/minutes/seconds Or decimal degrees: 22.Certification: (if well field,one lat/long is sufficient) :. . • . __ 35.5922824187' N -77.5996351267 ' w 10/18/2023'. • Signature of Certified Well Conti Date 6.Is(are)the well(s): ❑Permanent , or ®Temporary - By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with I SA NCAC 02C.0100 or I SA NCAC 02C.0200{Yell Construction Standards and that a copy of 7.Is this a repair to an existing well: ❑Yes. or .131 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 trader#21 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 tmtltiple injection.or non-water supply Wells ONLY with the same construction,you SUBMITTAL INSTRUCTIONS can submit one form: • 9.Total well depth below land surface: - ' 11.5 (ft.) - 24a.For All Wells: Submit this form within 30 days of completion of well - - For tniBdple Wells list all depths in d ferent(example-3@200'and 2@1002 construction to the following: . . • 10.Static water level below top of casing: 4' ' (ft.) Division of Water Resources,Information.Processing Unit,.. . If water 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 Synnly&Injection Wells: • . :Also submit one copy of this1forni 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 { , V V Geosyritec° - Boring Log . • . • consultants ---M-,, DRILLING CO.: _ ack-tA y\ " SITE: 6r.:4v1,014.cecosel, Boring ID: S Bt..)LA DRILLER: 'Gill- _Mil Le:‘,"' PROJECT NO.: GNetci4.,(49 Shet.: k of . \ Depth USCS/ Run Rec VOC Time Lithology Log Rock ft(Ws) (No.) (%) : (ppm) Notes/Sample ID Type r3.60 :"'VL.p3ci I - V.rri I - i tjk 15 LO1/4 _ ...._-- V -----, _ t.„_! 1[A,A--t95(1P LA.)rt. Sikl. 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