GW1--02100_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:
44"WATER ZOWS. I , , $ ; n<`,., ,a
Austin Fowler FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4366A ft. ft. 1
NC Well Contractor Certification Number =•.I :IPtiVt?R+CASC Utts1T7STDIG.(ebttiermalelosiii4nmii") " .RW!*:.:! ,'ILK....
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 3.8 ft. ' 1 in. Sch.40 PVC
Company Name ;1W.tit tit :ai 'tar miiiia s i(uvelffi 0iti YER:tfiiaifieab1e)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft. ft. in.
List all applicable well permits(i.e.Counry,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 3.8 ft. 13.8 R. 1 in. Slot.010 SCh.40 PVC
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. R. in.
❑Industrial/Commercial 0 Residential Water Supply(shared) FFRROM TO O• """'
MATERIAL EMPLACEMENT METHOD&AMOUNT
0 Irrigation
ft. R. ,
Non-Water Supply Well:
(XIMonitoring ❑Recovery R. ft.
Injection Well: ft. ft.
0 Aquifer Recharge 0 Groundwater Remediation 10i DIGRAVEL PACE:(trapplicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
<
R. ft. Surface Pour
❑Aquifer Test 0 Stormwater Drainage
0 Experimental Technology 0 Subsidence Control 0 R. 16 R
20 AtILL1N(r LOG faitaeh acltlitonat sheets if ileeessary'} ..., x.:t
❑Geothermal(Closed Loop) 0 Tracer FROM TO DESCRIPTION(color,hardness soil/rock type main size.etc.)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ft. R.
4.Date Well(s)Completed: 11/30/23 Well ID#: P4-TW36 R. ft. 40'e
ft. �® --
Sa.Well Location: AO
- \
ft. ft. �� 4 •` `.`r i.`• 1 "i
PIE-PS � �. .Y. •: ;,��::
R. P.:"
Facility/Owner Name Facility ID#(if applicable) - R•
APR 0 `� 2GZ4
PIT 4,Havelock,NC 28532 UL
Physical Address,City,and Zip ft. ft. Im , '1 7 l t x
ZL REM1S , as -r
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) , ��
34.90812431 N -76.88948629 w � , - 1/22/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or CD Temporary By signing this form,'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 ll 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
can submit one form. SUBMITTAL INSTRUCTIONS
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 derent(example-3 a 00'and 2@100) construction to the following:
10.Static water level below top of casing: 10.18 (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: 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