GW1--02103_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:
.,a`I QmitTEttiQ1Yai.>;;: " :. ::
Austin Fowler FROM TO , DESCRIPTION
Well Contractor Name ft. ft. 1
4366A ft. ft. 1
NC Well Contractor Certification Number :IS.INI*it itkiSidtit<€`IthaiidttQaterara€'elase<C•gOM . . , fi
FROM . TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 5 ft. I 1 in. Sch.40 PVC
Company Name MOCiBittMOINditaiiiiiitiktAitiiiiiabitEThlakiNlniInibiaMMMEggimm
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): liti
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS •yMATERIAL
❑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.
❑Industrial/Commercial 0 Residential Water Supply(shared) Itt:GR(NI'r" " '•�i` ' "'E ak
FROM TO MATERIAL EMPLACEMENTMEIHOD&AMOUM•
0 Irrigation
ft. ft.
Non-Water Supply Well:
®Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
0 Aquifer Recharge ❑Groundwater Remediation aNgOnditAitt'AEh.(iY titieabtel> ..f •:'
FROM , TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage ft. ft. Surface Pour
❑Experimental Technology ❑Subsidence Control Oft. 16 tt
ENCiiiiiiteiNd.edditiiiiiiiE3ditttitinal sheets if aecessarf!}i is
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,soil/rock type wain size.etc)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ft. ft. i
4.Date Well(s)Completed: 11/29/23 Well ID#: P4-TW34 a' ft. t$
ft. e. to$ sp
5a.Well Location: ft. ft. 104"0—.'01,,--.,:—„,,..
r:.r. .
PIE-PS ft. �� �.- ..% as - ._�1
Facility/Owner Name Facility ID#(if applicable) n n❑
ft. /i f R 6 i.� ?074
PIT 4,Havelock,NC 28532
Physical Address,City,and Zip R -tt tr •' t
S..
swegen
CRAVEN ,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: '
(if well field,one latllong is sufficient) _J �f
34.90865177 N -76.89048616 w ---' —? 1/22/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ®Temporary By signing this form,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 El No this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nann•e of
the repair under#21 remarks section or on the back of this fore:. 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 construdion,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: 13.09 (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
t
13a.Yield(gpm) Method of test: 24c.For Water Svpplv&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.
i
Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016