GW1--00844_Well Construction - GW1_20240205

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Austin Fowler ncw.A.TERztousedmirvalzwifratomwmoon , "''
Well Contractor Name FROM TO , DESCRIPTION
ft.
4366A ft.
ft fr. f
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NC Well Contractor Certification Number 45A/U.l'Eft_CA,81.N0(fotiioo ti-etise4lWillii,L?It;L71iIER4fi ' ble) ..:F ',.,, 1 :;„;:
CATLIN Engineers and Scientists FROM TO DIAMETER I I THICKNESS MATERIAL
Name 0 ft 3.6 ft• 1 '° Sch.40 PVC
Company
36:iNNEm Astva>Ul2"T.Cd811 Aioih iiiii itosed400py :ti , ..kF :4.... ? ;
2.Well Construction Permit#: WM 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. !II
Water.Supply Well: -sl?:>SGREEN y,..-,.<&=va'l. .:,=;,r. .�if.IFNa i t,a azi�*.S., K )3.`.:. ,,.•.. �. ''31 :
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 3.6 it 13:6 ft• 1 1n' •0.010 0.010 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ' ft in.
Industrial/Commercial °Residential Water Supply(shared) -f$;oRo ,.W a f e , _ f ! ,
Irrigation FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 2.6 ft• Bentonite surface pour
x Monitoring °Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge °Groundwater Remediation '
3':SANDIGRAVELPACX(rfappitcabte .1, '" f F .=a' rg:dii,.xs
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL: EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 2.6 ft- 13.6 ft• #2 Medium Sand surface pour
Experimental Technology °Subsidence Control ft ft.
Geothermal(Closed Loop) DITracer nftd)ItILLAYCi1:OGlatticLaddttroirat°sixetsifnecess°ry) *„ -,nim;:: ,M s' ,<,>.
FROM TO DESCRIPTION(color,hardness,sail/rack type,grain size,etc.)
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) ft ft
4.Date Well(s)Completed:12/11/2023 Well ID#TM1N-07 ft. ft.
5a.Well Location: ft. ft
Geosyntec fr. ft. ' SEE ATTACHED
Facility/Owner Name Facility iD#(if applicable) ft. ft.
3628 S. Fields Street, Farmville, NC 27828 t• `' .y-' }'
Physical Address,City,and Zip
P I TT !tIt>REtt'fA .«'i gild V c `h«�i ,.iRt r.>>r��,q.,.Txigapi €' L tee
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County Parcel Identification No.(PIN) ' • I'cr•ii
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ` tion: Id r�/ "`�r ti""�`
(if well field,one lat/long is sufficient) 22.Cert'�tca 'v '' -
35.59278 N -77.5991 W } i�.. ts. 01/29/2024
6.Is(are)the well(s)DPermanent or XTemporary Signature of Certified Well Contractor Date
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: °Yes 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#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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: 13.6 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 a(�1 00'and 2 N100') construction to the following:
10.Static water level below top of casing:6.7 (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: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: HSA 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
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