GW1--02085_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: ``
mmommommeastoommousnommg
William J. Miller_ FROM TO "DESCRIPTION
Well Contractor Name ft. ft.
2927A ft. ft. i
NC Well Contractor Certification Number ,i5<TN R LA5CNG "tififtk tj eotliet3natsii. t4iiiif <E ` :R , ' . �-i
FROM TO DIAMETER 'THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 5 ft. I 1 in. Sch.40 PVC
Company Name :'is€}I]`i t it `A l *tine iiii iiiii(y'etis)i 7•+Ntre(if»mtiliCAU
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft. ft. i, in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): . -
tattrAMMINSMIEMENEMSEMSOMISMENIMEEMEM
Water Supply Well:' FROM TO DIAMETER SLOT ATE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 15 ft. 1 in. Slot.010 SCh.40 PVC
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft• T:Ein.
0 Industrial/Commercial : SGTtU1 " : N:.
AC, FNM. ETH< .: s0 Residential Water Supply(shared) FROM • : TO... FM.ARA EMP.LEMTO.D& MOUNT
❑Irrigation
Non-Water Supply Well: ft.
®Monitoring 0 Recovery ft. ft.
Injection Well: ft. ft.
0 Aquifer Recharge 0 Groundwater Remediation RiffigigiNgaitupArioniiiiiiiiireignigginentMOMMIONNSOMME
0 Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft. Surface Pour
0 Aquifer Test 0 Stormwater Drainage
❑Experimental Technology 0 Subsidence Control 0 ft 16 ft
28.IfliiiiitiI +I r'(attach.aclditioiiiiii eefs faeecssaiiiii " . . :
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color hardness,soil/rock type,emirs size,etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. ft. ' to
4.Date Well(s)Completed: 11/28/23 Well ID#: P4-TW30 rt. ft.
ft. ft. �� O
5a.Well Location: NA
ft.
PIE-PS ft. P,G -
ft. ��;
Facility/Owner Name Facility ID#(if applicable)
PIT 4,Havelock,NC 28532 ft. rt. 4.u'-' "r:
Physical Address,City,and Zip
CRAVEN
County Parcel Identification No.(PIN) In T„^^•>:'rr '�1 "7^S•'� r:j U7,,,t
i.o rAr Jai v,.:,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification: '
(if well field,one lat/long is sufficient)
34.9087647 N -76.8905241 w -- '•""--:.;- `--- 1/22/2024
Signature of Certified Well Contracts* Date
6.Is(are)the well(s): ❑Permanent or ®Temporary ,By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
15A 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 ONLY 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@1002 construction to the following: i
10.Static water level below top of casing: 14.04 (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 Injection 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,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 Sypuly&Injection 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 Resourdes Revised 2-22-2016