GW1--02102_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: "
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I4.WA'f�LiZ011"FI»5 ,,:;:. �..<...:x. .:.<.. „ r .e:<m,. ,; ,., ., ,
Austin Fowler FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4366A ft• ft, f
NC Well Contractor Certification Number AgINNERVASIINGORMIBINGrabiliiiiiiitiliiiiMOVONNONARIMMUM
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 5 ft. 1 in. Sch.40 PVC
Company Name gilgWfnnI:tXSKaififAitffWifgitWigitiiiIiiiitiiiftiiafeafiV,I,IMFMMI
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A e e in
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): .11l1 'SaCttrglti
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Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 15 it. 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)
FROM TO MANSIIIIIIIIIIMIINIIINIMIIIMMINNIMOIMMISS
ATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation
a. f.
Non-Water Supply Well:
®Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft. •
0 Aquifer Recharge ❑Groundwater Remediation I : NA/GRA1h EKietCfiWaaiilieabIII - z,,.
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft. , Surface Pour
0 Aquifer Test 0 Stormwater Drainage
0 Experimental Technology 0 Subsidence Control 0 R. 16 ft
2O DlRILL GLt)G(t€aeb'adrH iiiiiisheets l`aecessarf}' ;,,.E. : ..s. ..
❑Geothermal(Closed Loop) 0 Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type cram size,etc)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 11/29/23 Well ID#: P4-TW35 ft. R. �
ft. e. eO
5a.Well Location: �H
ft. ft.
PIE-PS - L
ft. pZi
i js f-.�.,'1 "
Facility/Owner Name Facility ID#(if applicable) . "''"' e " ...ft. _ n .'
PIT 4,Havelock,NC 28532 ft ft l 13 l L4
Physical Address,City,and Zip i RttS , ;
CRAVEN r d`t'C.3JG
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)
34.90880095 N -76.89065238 _ _ w 1/22/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 0 Permanent or ®Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
1 JA 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 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@200'and 2@100) construction to the following: ;
10.Static water level below top of casing: 12.32 (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:
(Le.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