GW1--00839_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
i
Austin Fowler 44 wATER7,L11VESmKem. „_ .,goo,,,. .,,f. . MMir=. ,r.==. 3: a.5,,.
Well Contractor Name FROM TO DESCRIPTION,
4366A ft. ft.
ft. ft
NC Well Contractor Certification Number
MVI7Tt.li CA511?TG(fornrislfi•cased�r"ic71s')L3B,-Y,I3VER fif apijifia'hle)a.;`V '"`,.,
CATLIN Engineers and Scientists FROM TO DIAMETERI I THICKNESS MATERIAL
Company Name y � } (� 0 ft. 2.75 ft. 1 !n• Sch.40 PVC
"k mot' 6.# +.a ��1fi IltNER,CA$04[r>OR•IVERIGaQi tyiernia7'ciusid4&41111; ' _„r, " .. ; ,,...',
2.Well Construction Permit#: FROM TO DIAMETER. THICKNESS MATERIAL '
List all applicable well construction permits(i.e.VIC,County,State,Variance,etc) ft. ft. l in.
-
3.Well Use(check well use): ft. ft' in.
l Water Supply Well: 3'a3SGREF.P(i .,'a te a rx: s,��,+.„,. _ a > , l :=.4 �,,.g.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
3Agricultural DMunicipal/Public 2.75 f'• 12.75f'• 1 in• ,0.010 0.010 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft, ft. in,
pindustrial/Commercial OResidential Water Supply(shared) 0181 rtOTll .,_ ?„ rtt ai, .a Y,. a;
'Irrigation FROM . TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1.75 ft• Bentonite surface pour
Monitoring DRecovery ft. ft.
Injection Well:Aquifer Recharge
'
ft. ft.
Groundwater Remediation •
19.:SrTNAIGIZA�EG1'AGICCfsaA»1ieaAlc} � :.., 3 , vr." .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 1.75 ft 12.75 f'• #2 Medium Sand surface pour
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer
26 I3R1I 13iVG 1C,.fatiaclt:addihoina7'sbeefs•rf pecnssarY]._ a
FROM •TO DESCRIPTION(color,hardness,soil/rock type,grain
....•Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) size,etc.)
ft. ft.
4.Date Well(s)Completed:12/11/2023 Well ID#TMV1/-08 ft. ft.
ft. ft. 1
Sa•Well Location: ,
Geosyntec ft. . ft. ' SEE ATTACHED
Facility/Owner Name Facility ID#(if applicable) ft. ,,.,, ft- ^- ,
3628 S. Fields Street, Farmville, NC 27828 ft• w t,ft::i ,ft ,.V
Physical Address,City,and Zip ftt r
PITT 21 13EMATtK3 ,_,: 1";. :a .., .lf A/Mf 2cM. e. „ .::1M _'
County Parcel Identification No.(PIN) •
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
LiW<.'': iit
(if well field,one lat/long is sufficient) 22.Certification:
35.59339 N -77.5989 w .
(,/,A4'
01/29/2024
6.Is(are)the well(s)OPermanent or 1Temporary Signature of Certified Well Contractor Date
x
By signing this form,1 hereby certt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or XE No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under r21 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.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12.75 (ft.
P ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@100') construction to the following:
10.Static water level below topof casing:7.36
(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter:4•25 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: F ISA 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 Supply&Iniection,Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016