GW1--02095_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:
Austin Fowler FROM TO DESCRIPTION
Well Contractor Name ft. R.
4366A ft. R. I
NC Well Contractor Certification Number 15.1NNt R CAS NOOR111DINGj¢ieathe'rdial elosed400ts}..
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 3.7 ft. 1 1 in. Sch.40 PVC
Company Name -'(G.OU'i'L7i =A51NG(fit tnuttt caved ueusi OR LONER 4tf a1. Iitable) ,
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):
Water Supply Well: FROM , TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3.7 R. 13.7 ft. 1 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R. in.
❑Industrial/Commercial 0 Residential Water Supply(shared) i&GROUT .
FROM TO MATERIAL EMPLACEMENT METHOD R AMOUNT
❑Irrigation R. ft.
Non-Water Supply Well:
®Monitoring ❑Recovery ft. R.
Injection Well: ft. R.
❑Aquifer Recharge ❑Groundwater Remediation Ai SAND/GRAVEL PACK(If applicabtet• ',
❑Aquifer Storage and Recovery ❑Sal inity Barrier FROM , TO MATERIAL EMPLACEMENT METHOD
R. R. Surface Pour
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology IDSubsidence Control 0 R. 16 ft
20.•DROLLING•LUG(attach additional sheets fnEeessarf} ..
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,soiVrock type.Brain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R. R.
4.Date Well(s)Completed: 12/01/23 Well ID#: P4-TW41 ft. ft. stile __„,O
Sa.Well Location: ft. R.
G�ft. ft.
PIE-PS `�ft.
Facility/Owner Name Facility ID#(if applicable) - P.:
ft.
PIT 4,Havelock,NC 28532 ft ft tFtR U i• [U24
Physical Address,City,and Zip
21':REMAO2K;S �"
CRAVEN Ifl t� r4': ,I ;A;F:.Urn%
r.ix;rut.-A4-t.•.
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)
34.90810326 N -76.8892343 w 1/22/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ®Temporary By signing this fonn,1 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 ISINo 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 seine 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 n 00'and 2@I00) construction to the following: '
10.Static water level below top of casing: 10.44 (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 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.
Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016