GW1--01530_Well Construction - GW1_20240312

, i Print Form I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information: 1
Austin Fowler 14.WATER ZONES
WeIlCont�actorName FROM TO DESCRIPTION
4366-A ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
CATLIN Engineers and Scientists FROM TO 1 DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#'NSA •
FROM TO DIAMETER THICKNESS. MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) -4.25 ft• 15 ft. 2.0 in' 0.010 PVC .
•
IWell Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public 15 ft. 25 ft. 2.0 in' 10.010 0.010 PVC
Geothennal(Heating/Cooling Supply) Water Supply(single) JI
DResidentialft. ft. in.
0Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
nl Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
I Non-Water Supply Well: 1.5 ft. 19 ft. Bent. Chips Surface Pour
XnMonitoring 0Recovery ft. ft.
Injection Well:
ft. ft.
0Aquifer Recharge ©Groundwater Retnediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 17/Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fStonnwater Drainage 19 ft• 30 ft• #2 Medium Sand Surface Pour
8Experimental Technology .Subsidence Control ft. R.
Geothermal(Closed Loop) ®Tracer -20.DRILLING LOG(attach•additional sheets if necessary) •
FROM TO DESCRIPTION(color,hardness.soilirock type,grain size,etc.)
nGeothennal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:2-16-24 Well ID#MW-02 ft. ft.
5a.Well Location: ft. ft.
Geosyntec ft. ft. SEE ATTACHED
Facility/Owner Name Facility ID#(if applicable) ft. ft. �'^' -
100 Farmers Chemical Road, Winton, 27986 f fILi
Physical Address,City,and Zipft. ft.
y Hertford 21.REMARKS MAR ��
County Parcel Identification No.(PIN) ti -1r �:°-=IiFi
to tQ''(t ..c i't. •
.....
.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r�` �"',��
(if well field,one lat/long is sufficient) C rtification: F.,),...4
36.370055 N -76.868458 W ()A,
3-5-2024
6.Is(are)the well(s)nx Permanent or nTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certifi•that the well(s)was(here)constructed in accordance
7.is this a repair to an existing well: DYes or EINo with I5A 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
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-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: 30 (ft.) 24a. For All Wells: Submit this fonn within 30 days of completion of well
Formultiple wells list all depths ifdi/ferent(example-3 t@i 200'and 2 tt 100') 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 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 fonn 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
L where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

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Geosyntec Consultants Geosyntec D
Boring Log consultants
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DRILLING CO.: CA ILA N SITE: CF IVA L4G Boring ID: 1 O.„.
DRILLER: AASTI N -'— PROJECT Na: GN75112.10 Sheet: t of Z
Depth USCS/ Run Rec SPT/
ft(Ws) Time Lithology Log Type (No.) (%) RQD Notes/Sample ID
Z? S n1 CLAN(C CN5lY ),
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WELL CONSTRUCTION DIAGRAM - EPA TYPE II WELL (STICK-UP)
GeosyntecDE; tp N*tR-�+-rz 141/0 rZ
consultants DATE/TIME:2-IL-bitiqu WELL NO.:
WELL LOCATION:Ng¢iaED,tank,FIELD REP: A
NaRape C- ILeL. -
GROUND SURFACE ELEVATION: (ft,nisi) BENTONITE TYPE: t'lepi.y►.r� CH IPS— V1.10.:r}'en
TOP OF SCREEN ELEVATION: (ft,msl) MANUFACTURER: t.NIV Igo.Pi-Vt-r
BOTTOM OF WELL ELEVATION: (ft,msl) CEMENT TYPE: I-1(::t-Y STR (-71.{
NORTHING: EASTING: CEMENT MANUFACTURER: $ 1K.¢ETe.
SCREEN MATERIAL: PVC SAND PACK TYPE AND SIZE: -IN Pe 1 .
SCREEN MANUFACTURER: S)LvecZ Li t /112-oPu2E SAND MANUFACTURER: 05i
RISER MATERIAL: . fki(_ . DRILLING CONTRACTOR: Drill NI
RISER MANUFACTURER: SiW - L-lh.c tr."3v-tet,i,utzz AMOUNT BENTONITE USED: (6 bags_a lbs
RISER DIAMETER: 2 (in) Length: Zer (ft) AMOUNT CEMENT USED: 62 bagSSClbs
SCREEN DIAMETER: 2 (In) Length: I 0 (ft) AMOUNT SAND USED: 4, bagsR lbs
BOREHOLE DIAMETER: C l' (in) STATIC WATER: 36 0 f5 depth fro. e_•
DRILLING TECHNIQUE: t'15:�1' Size: -1.2� (in) ENCOUNTERED WATER: (W1 frlvi.a`"vfIeV-Up depth from ground
WELL DIAGRAM
Protective Pipe > Stick-up Height
PVC Pipe >l I I } Lif 2 _rT Ground Surface
♦niwnir HP! Dimensions of Concrete Pad
/, Z96x 29 I((e
�� Length Of Riser
ZZ SI 20 rr
C,, e
rl
1� 1 Depth To Top Of Bentonite
Total Depth Of
Depth To Bottom Well • • Depth To Top Of Sand
Of Hole 30 {
3d,, 1 _ lit
r '2.-zii Length Of Screen
iii e -
e = ID r1
Length Of Bottom Cap
` 31)_i ' di25f/-
ti : i ) a_,--____________,_, Length Of Sand Base
✓cATi" I
��� 1 BertoniteEll Bottom Cap
✓trs..�.{ Cement/Bentonite Grout Sand Pack Neat Concrete
QA/QC INSTALLED BY: AvsrfN t-OKSCe Z OBSERVED BY: I A-A)/02. Pc14
DATE: CHECKED BY: I DATE:
'if 0,11 . Gad& L5 tiq 1.1%1 Pro 415T.,`PsGGi