GW1--02101_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:
,14:WATE.RZONES;:,..,.. T
William J. Miller FROM , TO DESCRIPTION
Well Contractor Name ft. ft. 1
2927A rt. ft. 1
NC Well Contractor Certification Number AS.INNPACASIN6ORAIIDINGTftirithniiiii ctosed-tu°n}` "'"
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 5 ft. 1 1 in. Sch.40 PVC
Company Name it OIYY`I';ii t"ASt1s1G tt'uc rnaltt-sa5c 'weltsi Ili LPlirR'fttapl'rcabtej :>;
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft. rt. in.
List all applicable well permits(i.e.COurrty,State, Variance,Injection,etc.)
a. ft. in.
3.Well Use(check well use): S7.SChttii
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 R. 15 ft. 1 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) R. rt. in.
& ou'r
❑Industrial/Commercia] ❑Residential Water Supply(shared) i °` • •
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation
Non-Water Supply Well: ft. ft
IE Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation "1i)=SAND/G1tAV. PACK W'sppticablel'
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD u
0 Aquifer Test 0 Stormwater Drainage It. ft. Surface Pour
❑Experimental Technology 0 Subsidence Control 0 It 16 ft.
20 DIULL1 GLOG(attach add'tisanai sheets if neesssliry
❑Geothermal(Closed Loop) 0 Tracer FROM • TO DESCRIPTION(color.hardness,soil/rock type,main size.etc.)
0 Geothermal(Heating/Cooling Retum) 0 Other(explain under#21 Remarks) ft. a.
, 1 to
4.Date Well(s)Completed: 11/27/23 Well ID#: P4-TW22 ft. a. e
ft. ft. tip
5a.Well Location:
ft. ft.
PIE-PS p,:c� p ser. ;,-.
r,
Facility/Owner Name Facility ID#(if applicable) R. F' ``l. y
R. _
PIT 4,Havelock,NC 28532 Itil ft I V i.` 2614
Physical Address,City,and Zip
` " ' v ' "
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)
34.90875188 N -76.89039311 w __ -.., `„;� 1/22/2024
Signature of Certified Well Contract& Date
6.Is(are)the well(s): ❑Permanent or tEl Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
15A NCAC 02C.0100 or/5A 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 n formation 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:_ 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 a 00'and 2@100) construction to the following: ,
10.Static water level below top of casing: 10.8 (f,) 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 Svnply&Injection Wells:
Also submit one copy of this forth 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