GW1--02093_Well Construction - GW1_20240405

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14'i WA7ER'ZONES .,.,. «x.. . 3..
William J. Miller FROM TO , DESCRIPTION
Well Contractor Name ft. ft.
2927A ft. ft. 1
NC Well Contractor Certification Number
FROM FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 4.15 ft. ! 1 in. Sch.40 PVC
Company Name .[ C1tJ't1~It.i k4iiiiG`t"tai mutt axed tsl'tH UINtRi:tij`anirilt;sbie} .,•",,. +_
FROM TO II 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): t75CtiEEN`.s,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 4.15 ft. 14.15 ft. 1 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft• ft. in.
0 Industrial/Commercial C Residential Water Supply(shared) t$' "'' " " ' �` ''l "'4''
FROM ' TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0 Irrigation
R. ft.
Non-Water Supply Well:
®Monitoring ❑Recovery rt' ft.
Injection Well: ft. ft. '
0 Aquifer Recharge 0 Groundwater Remediation =I9:SAND/t R'AVEL PACK of arip#icable) .. it "` ,.., ,<<: , M ,.
TO MA
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TERIAL EMPLACEMENT METHOD
❑Aquifer Test 0 Stormwater Drainage R. ft. Surface Pour
❑Experimental Technology ❑Subsidence Control 0 rt. 16 ft.
:2@:DRILL ll(fir bG(attach ad'tditiooat.sheets if ascessari# A-`''
❑Geothermal(Closed Loop) ❑Tracer FROM TO : DESCRIPTION(color.hardness,soil/rock type.erain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) rt. rt.
4.Date Well(s)Completed: 11/28/23 Well ID#: P4-TW25 rt. ft. tclest
ft. ft. •V tiO
5a.Well Location: ��
ft. ft.
PIE-PS " ., ,
Facility/Owner Name Facility ID#(if applicable) ;,.,_
rt.
PIT 4,Havelock,NC 28532 ft (t. APR 0 i-` 2O 4
Physical Address,City,and Zip
CRAVEN Ir.,:,,-„^, :Tn 'r'^;<jn:;ag,UM
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)
34.9089797 N -76.89038192 w "� 1/22/2024
NAY _� .
Signature of Certified Well Conttadof. Date
6.Is(are)the well(s): ❑Permanent or IlaTemporary By signing this forni,I hereby certify that the wells)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: 14.2 (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@100) construction to the following:
10.Static water level below top of casing: 12.55 (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,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:
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.
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Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016