GW1--06098_Well Construction - GW1_20241014

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WELL CONSTRUCTION RECORD 'For Internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Information:
Todd Muench 14.WATER ZONES-
FROM TO DESCRIPTION
Well Contractor Name ft. ft. I I
3371 ft ft I 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETERI THICKNESS MATERIAL
Parratt-Wolff, Inc. ft ft. l 'in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM _ TO DIAMETER' THICKNESS MATERIAL
2..Well Construction Permit#: 0 ft. 5 ft. 2 in. sch40 pvc
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.) --- - -
ft. ft. i in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: - - FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft' 15 ft 2 '"' .010 sch40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation - 1 ft._ 2.5 -ft•-_ Bentonite-Chi-Pour- - -- -- - --- -
Non-Water Supply Well: ft ft
❑+Monitoring ❑Recovery
Injection Well: ft.. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage 2'5 ft 15 it #1 Sand Tremie
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer . .FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) • ft ' ft.
9-9-24 rt. ft.
4.Date Well(s)Completed: Well ID# ft. ft. '`I .s _
5a.Well Location: ft rt. •-"
USCG rt. ft. OCT 14 2C(24
Facility/Owner Name Facility Mt/(if applicable) ft ft. s
1664 Weeksville Road, Elizabeth City, 27909 Ir""""`'r •�- �'s'"`-v; .'"
ft. ft. I. , o'rv„,,,`.. `j
Physical Address,City,and Zip
21.REMARKS
Pasquotank 8°FMC -
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) '
36.26374 N -76.17584 -W jedd`1 c 9/24/24
Signature of Certified Well Contractor Date
6.Is(are)the well(s): IZPermanent or ❑Temporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of 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 INSTUCTIONS
9.Total well depth below land surface: 15 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 a 200'and 2@100') construction to the following: '
10.Static water level below top of casing: unknown (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service C''enter,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (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 completion of well
12.Well construction method: HSA construction to the following:.
(i.e.auger,rotary,cable,direct push,etc.) i'
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
13b.Disinfection type: Amount: well construction to the county hlealth department of the county where
constructed. !
Form GW-1 • North Carolina Department of Environment and Natural Resources-Division•of Water,Resources Revised August 2013