GW1--00842_Well Construction - GW1_20240205

pROPRUN974Nil
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ,
1.Well Contractor Information:
Austin Fowler i'ir{tVAT`ERIzo ES at f ,�R ,,r l ... , £t f.a; ,��,, ..._ . ;
Well Contractor Name FROM TO DESCRIPTION '
ft. ft.
4366A
ft. ft.
NC Well Contractor Certification Number 1,S p ;LrR byNG4foym a e>i`sid trelEsjO831?3N i it p' ble) ,:.U
CATLIN Engineers and Scientists FROM ' TO DIAMETER 1 ft. THICKNESS MATERIAL
02 84 ft. 1 in•{ Sch 40 PVC
CompanyName
lAiNi
0701312 . Afi/INNEI ASIlYGtITbT.EtBINGAiatfiicatn4cluidAtiajOci mZ._r: l ._. ...''
Z.Well Construction Permit#: FROM TO DIAMETER' , THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: gI "SCREEN--_ ,..:t,,..,w G . all 2 ,'sa; .1Wa .a..: ._._.. .._..
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 2.84 ft 12.84ft• 1 in- :0.010 0.010 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. - ft. in.
Industrial/Commercial DResidential Water Supply(shared)
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1.84 ft. Bentonite surface pour
x Monitoring DRecovety ft. ft. ;
Injection Well: .
ft. ft
Aquifer RechargeGroundwater Remediation 01b S ti/GANYyDMACK{ifiliMieabt`c7i',.. '..:x .. ,,:, ", wI P
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 1.84 ft. 12.84 ft• #2 Medium Sand surface pour
Experimental Technology 0Subsidence Control ft. ft. ,
Geothermal(Closed Loop) DTracer MDRi1'IIINOIDG,(attariz'addrtiogal"lierts,f uecesaars•)PM-= R-! Q> A§ 3.. :..;°xt
Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiUrocktvpe grain size,etc)
ft. ft.
4.Date Well(s)Completed:12/12/2023 Well ID#PZ-01 ft. ft.
ft. ft
5a.Well Location: '
Geosyntec ft. ft. SEE ATTACHED
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3628 S. Fields Street, Farmville, NC 27828 fLL -.:';
Physical Address,City,and Zip ft.' ,-'Eona, 'kit,G -i•' U;r:i"''i
PITTZ7R71114ARit9r� . a<;*;xc : a,�-mwza•,=:s .. : ..,a ,s.., x
County Parcel Identification No.(PIN) 20?4!
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ir1"�"/"'`'Cn �.;
(if well field,one lat/long is sufficient) 22.Cer' cation. d .$f1G 3 t..r{ri,
jam»
35.9303 N -77.6 w �` - F. s 6 A. 01/29/2024
x�Temporary Signature of Certified Well Contractor t Date
6.Is(are)the well(s)DPermanent or
By signing this form,I hereby certify that,the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or X 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 021 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
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: 12.84 (ft.) 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 2@100') construction to the following:
10.Static water level below topof casing:4.18
(ft.) Division of Water Resources,InformatioD Processing Unit,
If water level is above casing,use"- " 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.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: H SA 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&Injection 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