GW1--01529_Well Construction - GW1_20240312

I Print Form
W___ELL_CONSTRUCTION RECORD LGW-1) For Internal Use Only:
1.Well Contractor Information: I . ._
Austin Fowler l 14.WATERZONES- !
I FROM I TO i DESCRIPTION
Well Contractor Name
ft.•
4366-A •
ft. ft. I ;
NC Well Contractor Certification Number l_15..OUIERCASING-(for_�¢ulti-cased.wells)OR LINER(if.apRlicable)
CATLIN Engineers and Scientists -FROM. l TO -- _I DIAMETER_ _THICKNESS __I.MATERIAL
ft. ft. • in. I4
Company Name N/A lb.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO ❑IAMFTER THtrKNFSS MATFRIAI
List all applicable Well construction permits(i.e.UIC,County.State,Variance,etc.) -4 ft• -15 ft• 2 1n' 0.010 - PVC - ,-_
3.Well Use(check well use): ft. I ft. - _in.
17.SCREEN
I Water Supply Well:
FROM TO l-DIAMETER I SLOT SIZE -THICKNESS MATERIAL
•-Agricultural ElMunicipal/Public 15 ft. 25 ft• 2
ft.
1°' 0.010 0.010 PVC
.-Geothennal(Heating/Cooling Supply) Residential Water Supply(single) ft. in.
- Industrial/Commercial Irrigation
Residential Water Supply(shared) 18.GROUT
FROA1 TO MATFRIAI FM1IPI At FM1IFNT M1IFTHOn R•AMOUNT
Non-Water Supply Well: I 1.5 ft• 14 ft• bent.chips surface pour
x iMonitoring. - - _ -InRecovery - ft. ft.
Injection Well:
ft. ft.
*Aquifer Recharge OGroundwater Remediation
19.SAND/G 4VEL PAC (if applicable) _
'Aquifer Storage and Recovery Salinity Barrier FROM____TO MATFRIAI F111Pt 4CEMFNT METHOD
_!Aquifer Test OStonnwater Drainage 14 _ft• 25 ft• #2 Medium Sand surface pour .
1;J Experimental Technology OSubsidence Control ft. ( ft. I _____ _
lit Geothennal(Closed Loop) DTracer 20.DRILLING LOG(attar additional sheets if necessary) _.
_FROM TO— __ -- DESCRIPTION(color,business,soil/rock hype,Frain size.etc.)
!d Geothermal(Heating/Cooling Return) Other(explain under#21-Remarks),. ft. ft-.
4. Date Well(s)Completed:2/16/2024 Well ID#MW-0 ft. ft.
5a.Well Location: it. ft.
. Geosyntec . ft. ft. . SEE ATTACHED- .- - ____
Facility/Owner Name Facility iDk(if applicable) ft. ft. k[ i'-'"'s, 1 i .,- J ':
•
100 Farmers Chemical Road, Winton, 27986 __ ft. ft. w'� ��}'v'j --'' �' -' '`
Physical Address,City,and Zip ft. i_-_--_- ft. I MAR 1 2-.L0 24
Hertford .21.REMARKS _ . . - -_. _ - _.
County Parcel Identification No.(PIN) lniv i r i. (t' S;•ter:% li?
DWG.; OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one latflong is sufficient) :C rtification: /�1'1 u Fc,..a,.a.,,...
36.372897 -76.868222
N w
• 3-5-2024
6.Is(are)the wcll(s)1 Permanent or OTemporary ignature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or El No With 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Jl'ell Construction Standards and that a
If this is a repair,Jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under k21 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 i GW-I 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: 25 (ft.) 24a. For All Wells: Submit this fonn within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') construction to the following: '
10.Static water level below top of casing: (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:6 __(in.) 24b.For Iniection Wells: in addition to sending the fonn to the address in 24a
H.S. Augers above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
--- ' ' - - ' . Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) Method of test: 24c. For Water Supplv.&.injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fonn within 30 days of
13b.Disinfection type:____ Amount: 1 completion of well construction;to the county health department of the county
' where constructed. I
k
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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Geosyntec Consultants Geosyntec DP
Boring Log consultants
(DRILLING CO.: Q i { p! SITE: Cp i,J � Boring ID: MN
DRILLER: ..Ast15tt0 GwL�-Q. PROJECTNO.: C,-•07 6(0 • Sheet:. / .of
DRILLING METHOD: V191. DATE STARTED: 27 1(f„.L9 ,,oral IL cation c h Map/Reference
RIG: DATE FINISHED: Z-)to-Z+1
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BIT DIAMETER/TYPE: E{ 25-IISUPERVISOR: 6'4.
SAMPLE METHOD: PHOTO TAKEN: / i /2}e� Sests a
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Lithology Log
Depth Time USCS/Rock Run Rec SPT/ Notes/Sample ID/Water ,
ft(As) [Secondary/PRIMARY soil type,color,moisture,trace content, Type (No.) (%) RQD Level
density/consistency,plasticity,grain size]
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1 -_-)5'— 1?�0 Moles, O r/f toe of St N //
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(54p_Li10 Yez +.xti3rz ,0...9 % i
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WELL CONSTRUCTION DIAGRAM - EPA TYPE II WELL'(STICK-UP)
JOB NAME: CP Ki
Geosyntec ' c.7-N-7szokrtel_LL I
consultants DATE/TIME: i(0/Z4.Q 1336 WELL NO.:
WELL LOCATION:W r QQ, FIELD REP:Ar7r3Q.e u ' 77
1"Cf 4 C.A9.4..t Nir ��,
GROUND SURFACE ELEVATION: (ft,msl) BENTONITE TYPE: �+1 7LUwl CHIPS—UN(;th4"ie0
TOP OF SCREEN ELEVATION: (ft,msl) MANUFACTURER: 6Ntlt{Zi,Pt,Ui
BOTTOM OF WELL ELEVATION: (ft,msl) CEMENT TYPE: }!11 txt•t STrtcNia-Zi-t
NORTHING: EASTING: CEMENT MANUFACTURER: c(}r rzere ,
SCREEN MATERIAL: Pic SAND PACK TYPE AND SIZE: l'APV2 l
SCREEN MANUFACTURER: iLVC12 UNE ENVit-ifbite SAND MANUFACTURER: 1.) 1
RISER MATERIAL: PVC DRILLING CONTRACTOR: C$T TLI N
RISER MANUFACTURER: ck..Jl &(AIX ENVIP-.OPUIz.E AMOUNT BENTONITE USED: g . bags.3)Ibs
RISER DIAMETER: '2. (in) Length: 19 (ft) AMOUNT CEMENT USED: bags97lbs
SCREEN DIAMETER: 2 (in) Length: %b (ft) AMOUNT SAND USED: 7 bagsSt5 lbs
BOREHOLE DIAMETER: Le (in) STATIC WATER: 2 717 depth fro TOC
DRILLING TECHNIQUE: H54 Size: 4,2c (in) ENCOUNTERED WATER: f)i)"T 1 NY"r'DWI ,depth from ground
WELL DIAGRAM
Protective Pipe
Stick-up Height
PVC Pipe } ,`1t
_ Ground Surface
•••• ••••• ••••• Dimensions of Concrete Pad
{ to * �24° 'ace" X(o it
•w I R i , Length OOff Riser
F : ]
t N Depth To Top Of Bentonite
i Lc
Total Depth Of
Depth To Bottom Well Depth To Top Of Sand
Of 251�e ZS =S l Li
_e
r Length Of Screen
e_ (6 Fr
Length Of Bottom Cap
25,2‹ in,
Length Of Sand Base
zsr ;ii<i
Qtvv
ages. Cement/Bentonite Grout Sand Pack =. Neat Concrete Bentonite ill Bottom Cap
QA/QC INSTALLED BY: A ci(((j ED-4, (Z OBSERVED BY: I q'N)32Ev,1) PUT/
DATE: CHECKED BY: DATE: