GW1--06099_Well Construction - GW1_20241014

WELL CONSTRUCTION RECORD For Internal Use ONLY: .
This form can be used for single or multiple wells
1.Well Contractor Information: ,
Todd Muench 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
3371 ft. ft.
NC Well Contractor Certification Number 15.OUTER (for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL .
Parratt-Wolff, Inc. ft. ft. 1, 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,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 5 ft. 15 ft. 2 i" 010 sch40 pvc
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑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.
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑
2.5 ft. 15 ft- #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soi/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
9-9-24 ft. rt.
4.Date Well(s)Completed: Well ID#
ft. ft. ^
5a.Well Location: ft. ft. ' '`� °^ ..• .'L.s4 -.4) :..!'.4.:,4 ,�,,,.,.
USCG ft ft.
lity/Owner Name Facility IDb(if applicable) OCT11� 1 4 /�?�
J
ft. ft.
1664 Weeksville Road, Elizabeth City, 27909 ft, fL ihr:�.;,n.,::. :•a:-, �„rt
. f>,
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 _�t %�,id%/ uQ, 9/24/24
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 21Permanent or ❑Temporary By signing this form,I hereby cert(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
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@200'and 2@I00') construction to the following: i
1
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 Center,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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of W ater Resources Revised August 2013