GW1--06898_Well Construction - GW1_20231030

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells .
1.Well Contractor Information:
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14.WATER ZONES •
William J. Miller FROM - TO DESCRIPTION •
• Well Contractor Name ft.. ft. 1
2927A . . . . ft. ft.
NC Well Contractor Certification Number 15.INNER CASING OR TUBING(geothermal closed-loop)
FROM • '' '•TO DIAMETER . THICKNESS MATERIAL
CATLIN:Engineers and Scientists • 0 a...• • 1.3 ft. ' ••1 i• in: Sch.40 •- PVC
Company Name . 16.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
N/A FROM _ TO _ DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: e... ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc).• - . .
3.Well Use(check well use): - • -- • 17.SCREEN
Water Supply Well: FROM TO - ' DIAMETER SLOT SIZE- THICKNESS MATERIAL •
❑Agricultural ❑Municipal/Public 1.3 ft. , 11.3 ft. ' 1 in. Slot.010- -Sch:40 . PVC
❑Geothermal-(Heating/Cooling Supply) . El Residential Water Supply(single) .... : :R• ft. . in. • . ..
' ❑Industrial/Commercial ' 0 Residential Water Supply(shared) 18.GROUT
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FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT •
❑Irrigation e rt.
NomWater Supply Well: :
El Monitoring .. ❑Recovery 0 ft. 0,5 it.
Injection Well: ft. . ft.
❑Aquifer Recharge • El Groundwater Remediation . 19.SAND/GRAVEL PACK(if applicable)
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ElAquifer Storage and Recovery El Salinity Barrier. -FROM TO MATERIALEMPLACEMENT METHOD
0.5 ft: 11 ft. Torpedo Sand Surface Pour
❑Aquifer Test. 0 Stormwater Drainage
❑Experimental Technology 0 Subsidence.Control
ft. ft. .
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed loop) ❑Tracer. FROM TO - ' DESCRIPTION(color,hardness,soil/rock type,Brain size,etc.)
❑Geotfiennai(Heating/Cooling Return).
CI Other(explain emarks) ' n
0 26/23 . R.
4.Date Well(s)Completed. Well ID#: SB03ITMW 3
e. :ft. S� O
5a.Well Location: •'Geosvntec 11$14CP‘Iii
R. T'
Facility/Owner Name . Facility ID#(if applicable) ,; ' -`-
3648 S.Fields Street,Farmville,NC.27828 • q
Physical Address,City,and Zip R• n( T ' 'li ,-Qt J
21.REMARKS
PI 1T 1T • • . int r,.:..^-i! P.'', _ . >,'an:M.x -
• County • . • .. Parcel.Identification No.(PIN) . . Di`;.C:_'I'DE.4 W
•5b.Latitude and Longitude in degrees/minutes/seconds Or'decimal degrees: 22.Certification: '
(if well field,one lat/long is sufficient) • _
35.592725955 N -77.5997351147 .w 10/18/2023:
Signature of Certified Well Contlacd • Date
6.Is(are)the well(s): ❑Permanent 'or III Temporary By signIngthis form,I hereby certify that thewell(s)was(were)constructed in accordance with
15A NCAC 02C.0100 or 1 SA 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#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 multiple'injection or non-water supply Wells ONLY with the same construction,you
can submit one form. . . SUBMITTAL INSTRUCTIONS •
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9.Total well depth below land surface: ' ...1 1.3 .(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@200'and 2@100) construction to the following:
10.Static water level below top of casing: 4 (ft) Division.of Water Resources,Information.Processing Unit,
Ifwater 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:
• (Le.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&Injectionl Well's:
.. _ Also submit one copy of this form within'30•days of completion of well
13b.Disinfection type: Amount: construction to the county health department of the county where constructed.
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Adapted from:Form GW-1 North Carolina Department of Environment and Natural Resources-.Division of Water Resources • Revised 2-22-2016

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Geosyntec Consultants . eOSyntec
Boring Log consultants
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DLER: • PROJECT NO.: 6 • Sheets RIL ' l .•-.of. ` 1,
DRILLING METHOD: DATE STARTED:•
Borehole Location Sketch Map/Reference
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. RIG: p[ Gr-• P.iro.be_ _: DATE FINISHED: b�tiatela. / '
BIT DIAMETER/TYPE: _'21 I SUPERVISOR:. Mo . • oIP`1
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Depth: : ,Lime USCS:!Rock Run ,Res_: _VOC.• Notes/Sample ID,/Water
ft(his)' Level •
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