GW1--02094_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:
lliAustin Fowler FROMnTiR`zoNo s r 'DESCRIPTION
Well Contractor Name ft. ft.
4366A ft. ft.
NC Well Contractor Certification Number =IS INNER+CASINC>Oit`tIBItgd eaitieiiiat'ctodFteop .. . . ,
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 3.8 ft. I 1 ift. Sch.40 PVC
Company Name `ft Ot)ltlf ASINGifar muitl-tadeir wefts}OR LINER tifsfiip[iiiiili
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.)
R. ft. in.
3.Well Use(check well use):
IZ fiCR�i P!, M:;:;:•;'i',- 1::•:&U N ,.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS• MATERIAL
❑Agricultural ❑Municipal/Public 3.8 I. 13.8 ft. 1 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) tr. rt. in.
❑Industrial/Commercial 0 Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation
ft. ft.
Non-Water Supply Well:
®Monitoring ❑Recovery ft.; ft.
Injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation `t SAND/GRAVEL.PACK 0ramsR eab1e
FROM , TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Storage and Recovery 0 Salinity Barrier
ft. ft. Surface Pour
❑Aquifer Test 0 Stonnwater Drainage
0 Experimental Technology 0 Subsidence Control 0 R. 16 R
20 fRlLL LOG"(attach auidttitiaai sbeets if necessurv}' 'S..'• .,, v.
0 Geothermal(Closed Loop) 0 Tracer FROM TO DESCRIPTION(color hardness,soil/rock type,resin size.etc.)
❑Geothermal(Heating/Cooling Retum) 0 Other(explain under#21 Remarks) R. R.
4.Date Well(s)Completed: 12/01/23 Well ID#: P4-TW42 rt. n. �
R. e. *®
5a.Well Location:
ft. n. or
PIE-PS ft. " % L L +'•ii
Facility/Owner Name Facility ID#(if applicable)
PIT 4,Havelock,NC 28532 ft. APR 0 r 21
ft. ft.
Physical Address,City,and Zip 2I/tExtigi{$ lf.Ki.Rr: - NI 'NI , J 13s ti ,...
CRAVEN G```VO.130
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one la/long is sufficient)
34.90830789 N -76.88919002 w �jy�j 1/22/2024 _
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 0 Permanent or ®Temporary By signing this fonn,I hereby certify that the well(s)war(were)constructed in accordance with
ISA 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 tinder#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: 13.8 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths in dierent(example-3 a 00'and 2@I00) construction to the following:
10.Static water level below top of casing: __ 10.23 (g,) Division of Water Resources,Information Processing Unit,
Ifwater 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
l
13a.Yield(gpm) Method of test: 24c.For Water Svpply&Injection Wells:
Also submit one copy of this form within 30 days of completion of well
construction to the county health department of the county where constructed.
13b.Disinfection type: Amount:
Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016