GW1--02084_Well Construction - GW1_20240405

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
4'4 N4MTFttZONES :... ;!,I : ..,ra !> ;5.
William J. Miller FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2927A ft. ft. l
NC Well Contractor Certification Number =I5'1N1 sCivaDi='ttra ea Hemel.=clam u m ...�.,r .:<s ,
mmen
FROM TO DIAMETER _ THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 It. 5 ft. ! I in. Sch.40 PVC
Company Name :'ifi.4Ti`l +t"ASiI fffl;"rout i€ii tsl t38]utN ttf unat€catiti
FROM _ TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): gilatitEMEMEINVERNEMISOMERMIERMOMOMMEGIONVERI
•
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 rt. 15 ft. 1 in. Slot.010 Sch.40 PVC
Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. . ft. in.
0 Industrial/Commercial 0 Residential Water Supply(shared) FROM' a "" " "' '" `" `"
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation
ft. ft.
Non-Water Supply Well:
®Monitoring 0 Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation 5 I :'StA1 DIGRAYJh.•r<PACIC(111appl€eabte} ,.;? „:,M :gn:;,:: :: K.. M
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test 0 Stormwater Drainage ft. ft. Surface Pour
❑Experimental Technology 12Subsidence Control 0 ft. 16 ft
iitibitiEtiSt tifiatiitAMMilittaliiMiiiiiiiiiiaiiiMEHMENERSHOMMengt
❑Geothermal(Closed Loop) 0 Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
ID Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) rt. ft.
4.Date Well(s)Completed: 11/28/23 Well ID#: P4-TW31 rt. e. to�
ft. ft I V
5a.Well Location:
ft. ft � I p b gel 1 — . ,,
PIE-PS Y ,,
Facility/Owner Name Facility ID#(if applicable)
rt.
PIT 4,Havelock,NC 28532 ft ft. APR it ii, 2024
Physical Address,City,and Zip
CRAVENeggel
Y
County Parcel Identification No.(PIN) ,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lat/long is sufficient)
34.90864455 N -76.89037777 w __-----•— :,,;,-` 1/22/2024
Signature of Certified Well Contract& Date
6.Is(are)the well(s): 0 Permanent or ®Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of
7.Is this a repair to an existing well: ❑Yes or No this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of
the 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.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells O1VLY with the same construction,you SUBMITTAL INSTRUCTIONS
can submit one form.
9.Total well depth below land surface: 15.0 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths in different(example-3@200'and 2@l00) construction to the following::
10.Static water level below top of casing: 11.25 (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: 2 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the
address in 24a above,also submit a copy of this form within 30 days of
12.Well construction method: DPT completion of well construction to the following:
(i.e.auger,rotay,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
i
13a.Yield(gpm) Method of test: 24c.For Water Supply&Infection Wells:
Also submit one copy of this form within 30 days of completion of well
13b.Disinfection type: Amount: construction to the county health department of the county where constructed.
Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016
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