GW1--01531_Well Construction - GW1_20240312

IPrint Form I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: '
1.Well Contractor Information:
Austin Fowler 14.WATERZONES '
FROM TO I DESCRIPTION
Well Contractor Name
ft. ft. I
4366-A
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if appIlicable)
CATLIN Engineers and Scientists FROM TO I DIAMETER THICKNESS I MATERIAL
fL 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.) -3.63 ft• 10 ft. 2.0 1°' 0.010 PVC
3.Well Use(check well use): ft. ft. in.
17.SCRE N
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
°Agricultural f MunicipallPublic 10 ft. 20 ft• 2.0 in' ' 0.010 0.010 PVC
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in.
inIndustriaUCommercial Residential Water Supply(shared) 18.GROUT '
NIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
on-Water Supply Well: 1.5 ft. 8 ft. I Bent. Chips Surface Pour
Monitoring °Recovery ft. ft.
Injection Well:
ft. ft.
jAquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ©ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
°Aquifer Test f Stonnwater Drainage 8 ft• 20 ft. #2 Medium Sand ISuriace Pour
Experimental Technology nSubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soiVrock tree,grain site.etc.)
nGeothennal(Heating/Cooling Return) nOther(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:2-1 5-2024 Weil ID#MW-03 ft. ft.
5a.Well Location: H. ft. I
Geosyntec ft. ft.. SEE ATTACHED •
�.
Facility/Owner Name Facility ID#(if applicable) R. ft. f....,77 im: e\ A ;f
100 Farmers Chemical Road, Winton, 27986 ft. ft. s '6 r. i.,r rw,,..I. tr aTM b..
Physical Address,City,and Zip ft. ft. MAR 12 CO24
Hertford 21.REMARKS
County Parcel Identification No.(PIN)
Telco '3'-g
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) .C rtification: (/I „o /36,370815 N -76.866785 ��
3 -5 -2024
6.Is(are)the well(s)n Permanent or °Temporary Signature of Certified Well Contractor Date
By signing this forms,I hereby certi)5,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or °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:
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
t
9.Total well depth below land surface: 20 (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@200'200'and 2@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 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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Boring Log I consultants
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DRILLING CO.: ce--TJ j SITE: (F Nil at„reN Boring ID: M W 03
DRILLER: NS_t1tyFDALaz PROJECT NO.: Cr147540L0 Na/ Sheet: of
DRILLING METHOD: Hip, DATE STARTED: Z/l 5/29 B off(1c t SkctJ O
Loea ap`/'Reference
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RIG: c"IG 4ci3 • DATE FINISHED: •2//51Z• 4
BIT DIAMETEIUTYPE: ( ,-al, SUPERVISOR: A t..oQEtN fiv'17 c11111..
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SAMPLE METHOD: .NSA 4'2 ctc'hft PHOTO TAKEN: `-WS • .. ep i
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Lithology Log
Depth Time USCS/Rock Run •Rec SPT/ Notes/Sample ID/Water
8(Ws) [Secondary/PRIMARY soil type,color,moisture,trace content, Type (No.) (%) RQD Level
density/consistency,plasticity,grainsize]
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WELL CONSTRUCTION DIAGRAM - EPA TYPE II WELL (STICK-UP)
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Geosyntec '— JOB ME: Mw3
consultants DATE/TIME: Z-tC-24 / WELL NO.:
WELL LOCATION:10 t0U Ciatav-ty FIELD REP: 11,foR Purr
t e--X G4412.e:u6.
GROUND SURFACE ELEVATION: (ft,msl) BENTONITE TYPE: VW Ct;ft-RV-MtP0IUVI l.Hi PS
TOP OF SCREEN ELEVATION: (ft,msl) MANUFACTURER: Mil 12.0 PO/t r
BOTTOM OF WELL ELEVATION: (ft,msl) CEMENT TYPE: I-1iL-(-I S?(LDvi(H
NORTHING: EASTING: CEMENT MANUFACTURER: S 0 le--17-er e
SCREEN MATERIAL: NC. . .- SAND PACK TYPE AND SIZE: Ti' • Pe I
SCREEN MANUFACTURER: . Slim ea- Utz eNui1LO(2u2E SAND MANUFACTURER: OS 1
RISER MATERIAL: NL . DRILLING CONTRACTOR: C.PM-t kJ
RISER MANUFACTURER: Siurea- LANE Eh1V 1rLDR.1(2i' AMOUNT BENTONITE USED: 4 bags5-D lbs
RISER DIAMETER: .2.. (in) Length: 1 3,(0'3 (ft) AMOUNT CEMENT USED: (0 bags S Ibs
SCREEN DIAMETER: .2 (in) Length: t)O (ft) AMOUNT SAND USED: ` i- / bags SO Ibs
BOREHOLE DIAMETER: C9 (in) STATIC WATER: rig lQ depth from TOC
DRILLING TECHNIQUE: 1-154 Size: 11.2S (in) ENCOUNTERED WATER: tIAT 1 Oct- depthfromground
WELL DIAGRAM
Protective Pipe Stick-up Height
PVC Pipe -},_
Ground Surface .. P to 3
•••• •••••• N••s Dimensions of Concrete Pad
•••• •N•• •N•41
v ,i-' - Length Of Riser
v.• t '�J
�.i ,.s. :�✓,, IC
r
6 Depth To Top Of Bentonite
1c 1�5 c-i 3L�
Total Depth Of '
Depth To Bottom Well Depth To Top Of Sand
Of Hole 20Y(
S = 8 VI (34S
�U, f5L5 c
r - Length Of Screen
e 10
Length Of Bottom Cap
26.2S-.
201
l i_: i i a- Length Of Sand Base
✓J/�C
�i� Cement/Bentonite Grout Sand Pack ••• Neat Concrete Bentonite IIII Bottom Cap
'. _ ' QA/QC INSTALLED BY: AUg'ItAJ ' w[ TL OBSERVED BY: ; fit
DATE: CHECKED BY: DATE: