GW1--06899_Well Construction - GW1_20231030

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WELL CONSTRUCTION RECORD: ' '' For InternalUse ONLY: I
This form can be used for single or multiple wells ' ..
• . • - 1,Well Contractor.Information: ; , "' -
14.WATER ZONES
William J. Miller FROM • TO DESCRIPTION
Well Contractor Name •• •• 'ft. ft. i 1 - - . - •
2927A - . e. a.
NC Well Contractor Certification Number 15.INNER CASING OR TUBING(geothermal closed-loop)
. . FROM. . .:TO DIAMETER - THICKNESS MATERIAL
CATLIN Engineers and-Scientists •• :O•ft._ ' 2 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/A • ... ft. It
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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural - ❑Municipal/Public.. _ ,2 R. • 12 ft. • 1 .. in. Slot.010' Sch:40 PVC '
❑Geothermal:(Heating/Cooling Supply) ' . 0 Residential Water-Supply(single) .ft. : ft. . in.
❑Industrial/Commercial' 0 Residential Water Supply(shared). 18.GROUT
• FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT - -
. 0 Irrigation ---
• a. a.
Non-Water:Supply Well: . . ' .--.
. IR Monitoring. .. . 0 Recovery .. 0"ftr 1 ft. .
•• Injection Well:- •.: .. •. ft. 2 ': _
❑Aquifer Recharge. :. . . 0 Groundwater Remediation . . • 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ': : . 0 Salinity Barrier''. FROM TO MATERIAL EMPLACEMENT METHOD-7— '
• ❑Aquifer Test • • ❑StormwaterDrainage . 1.tt. 12 ft. Torpedo Sand Surface Pour
0 Experimental Technology ' . O Subsidence.Control rt. ft. ,;
20.DRILLING LOG(attach additional sheets if necessary)
• ❑Geothermal(Closed Loop) : ❑Tracer . _ - -• FROM TO - DESCRIPTION(color,hardness,soil/rock type,main size,etc.)
0 Geothermal(Heating/Cooling Return)-' ' 0 Other(explain under#21 Remarks) .fi. a. . •
- • -4.Date Well(s)Completed: 09/26/23 Well ID#h: SB02/TMW-2 : .. to
rt. R.
5a.Well Location:
Geosyrltec - ram-- _
Facility/Owner Name . Facility ID#(if applicable). 1 P` '� fr...." '' 7--,ft. �... a.a :.
•3648 S.Fields Street,Farrnville,NC.27828 rt. rt. U( T 3
• Physical Address,City,and Zip 20,�
. :.. 21.REMARKS
' PITT ' .. Irtior ::.n Pr^ -.w.i -n it-01
County -Parcel Identification No.(PIN),: ~"
5b:Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22..Certification: .
(if well.field,one lat/long is sufficient) • • .
35.593043659 . : N -77.599645527 . W . '' : : _ 10/1812023'. .
.•Signature of Certified Well.Cont r .. • Date
6.Is(are)the well(s): ❑Permanent or ®Temporary By signing this form,1 hereby certify that'the well(s)was(were)constructed in accordance with
• 15A 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 MI 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 tinder#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
S.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 coitstiitction,you SUBMITTAL INSTRUCTIONS
can submit one form. '
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9.Total well depth below land surface: -" 12.0 (g,)-•.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 r@100)'' ' construction to the following: .
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: ::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.;Forinjection'Wells ONLY: In addition to sending the:form to the -
address hi 24a above,also submit a copy of this form within 30 days'of
12.Well construction,method: Polder 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 one copy of thisi forth 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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' DRILLING CO �l -Tl�t ln. ' SITE:.. G _.er'brj n- Boring•ID: S ®.',
DRILLER: (1 , i�,e . PROJECT 6,:::-.0A441;.(' ., _ Sheet1 1 of
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Time . Lithology Log • : . Rock u • Notes/Sample ID
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