GW1--03096_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Eddie Swain 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
4632-B rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
CATLIN Engineers and Scientists FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
W M 0 7 01312 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. U/C,County,State,Variance,etc.) 0.0 ft. 2.5 ft. 2.0 in. 0.010 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERAAI.
Agricultural °Municipal/Public 2.5 ft. 12.5 ft. 2.0 in' 0.010 0.010 PVC
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOI\1
Non-Water Supply Well: 0.5 ft. 1.5 ft. Bent. Chips Surface Pour
X Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 1.5 ft. 12.5 ft- #2 Medium Sand Surface Pour
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) ['Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed:4-23-2024 Well ID#MW-04 ft. ft.
5a.Well Location: ft. ft.
Geosyntec NA ft. _ ,
r L t
Facility/Owner Name Facility Mil(if applicable) ft. ft.
3648 S. Fields Street, Farmville, NC it. ft. - MAY 1
Physical Address,City,and Zip ft. ft.
Pitt 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one lat/long is sufficient) 22.CertiBeadon//:
35.5933929982 N -77'5989235362 w , �7. . 5/8/2024
6.Is(are)the well(s)Ix Permanent or DTemporary Signature of Certified Well tractor Date
By signing this form,/hereby cent that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or XpNo with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
1f this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#2/remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12'5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (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:4.25 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: H SA 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 SuDDly & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016