GW1--02099_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:
1ii.WATER;ONI.S ,, ,
Austin Fowler FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4366A R• ft. I
NC Well Contractor Certification Number :] INAIERltAAINdtiit HWIST6YanfiiirmatiatAiii.Wit;i r1,
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 5 ft. 1 1 in. Sch.40 PVC
Company Name I4:Li13 APi tia'ftur molt€can i ielli O IASI Paixht'rtable .
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 5 ft. 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) `i8`t;Rt1TJ1
FROM TO MATERIAL EMPLACEMENT METHOD 8 AMOUNT
0 Irrigation
Non-Water Supply Well: rt. ft.
ft. R.
CMMonitoring ❑Recovery,
Injection Well: ft. ft.
0 Aquifer Recharge 0 Groundwater Remediation 14:'SAND/GPAM'EL.PAG•K{iYnppf etiblel"
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
rt. ft. Surface Pour
❑Aquifer Test 0 Stormwater Drainage
❑Experimental Technology 0 Subsidence Control 0 it• 16 ft.
I 2GDRltllf LOGtittacl atlettnl'sheets ifneeessary)
❑Geothermal(Closed Loop) 0Tracer FROM TO . DESCRIPTION(color,hardness,soil/rock type cram size,etc.)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) I R. n.
4.Date Well(s)Completed: 11/30/23 Well ID#: P4-TW37 ft. a'- : v-�-
ft. ft. �O
5a.Well Location:
ft. R. Ipik,wit,,- : . I.' a
4 Tar'Z,.`.•dnu�, •Q
PIE-PSKitli
ft.
Facility/Owner Name Facility ID#(if applicable) ft. APR fl n n D i.; 2024
PIT 4,Havelock,NC 28532
Physical Address,City,and Zip ft• R
a t P A.10f ',:,i 4
CRAVEN
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)
34.90829067 N -76.88947785 w �/ 1/22/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ®Temporary By signing this form,I hereby cent&that the well(s)was(were)constructed in accordance with
15A NCAC 02C.0100 or I5A 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#2I 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 stone 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 d/Terent(example-3@200'and 2@1009 construction to the following:,
10.Static water level below top of casing: 10.97 (g,) 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: OPT 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
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13a.Yield(gpm) Method of test: 24c.For Water Svpnly&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
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