GW1--06214_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD For Internal Use ONLY: ,
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin White 14.WATER ZONES '
FROM - TO DESCRIPTION
Well Contractor Name ft. ft. I
2973A ft. ft. i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft
Parratt-Wolff, Inc. in. .
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) - '
FROM , TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. g 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 ❑Municipal/Public 9 ft. 19 r`' 2 '"'' 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 0 ft. 5 ft. Portland Cem Pour
Non-Water Supply Well:
2Monitoring ❑Recovery 5 rt. 7 ftBentonite CHI Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑A uifer Storage and Recovery ❑Salini Barrier -
q g 7 ft. 19 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) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
9-18-24 LFG-5 ft. ft. !,0 7;..-_.t. .+G.: 1, L.1 2...-
4.Date Well(s)Completed: Well ID# • ft. ft. i
5a.Well Location: ft. ft. O C I 3 1 2024
Pender County Pender Co Landfill ft. - ft. inn5;r E P� r7r,;._,!_ �,_sa.
Facility/Owner Name Facility ID#(if applicable) ft. ft. L:,l .i.-'
'✓u
3280 New Savannah Road, Burgaw 28425 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Pender 3209-1370-0000 2 X 2 Pad
County Parcel Identification No.(PiN) 4l'ProCover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: I'
(if well field,one lat/long is sufficient)
34.550277 N -77.986856 Nt l (� . �/
Signature of Certified Well Contract Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby terrify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or i5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or MNo copy of this record has been provided to the well miner.
If this is a repair,fill out known well construction information and explain the nature of the l
repair under 421 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 saute construction,you can I
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 19 (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 tr 200'and 2@i00') construction to the following:
10.Static water level below top of casing: 20 Division of Water Res
(ft.) ources,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
(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 m Method of test: 24c.For Water Supply&Injection Wells:
(gP ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county li ealth department of the county where
constructed.
I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water.Resources Revised August 2013
1,