GW1--06218_Well Construction - GW1_20241021

i
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 ap licable)
FROM TO DIAMETER THICKNESS' MATERIAL
Parratt-Wolff, Inc. ft. ft. I in.
I.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit tt: 0 ft, 7 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 7 ft. 17 ft 2 '"" .010 sCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. '"•
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT,
FROM _ TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rt. 3 ft- Portland Cem Pour
Non-Water Supply Well:
i lMonitoring ❑Recovery
3
-. _ ft. 5 ft- Bentonite Chii Pour
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_
5 ft- 17 ft, #1 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(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.
9-19-24 LFG-2 rt. rt. i:.
~
4.Date Well(s)Completed: Well ID# ft ft. t .
5a.Well Location: ft. ft. OL T / I Z07A
Pender County Pender Co Landfill ft ft. L`t
Facility/Owner Name Facility lDf#(if applicable) 1F��'•:'.'^,i'`' -r.-.-.-,.,_..,,.•.
rt. ft.
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) 4"ProCover
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
34.548053 N -77.986557 /0•(q• a Li
Signal Well Contractor ; Date
6.Is(are)the well(s): OPermanent or ❑Temporary
By signing this form,I 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
7.Is this a repair to an existing well: ❑Yes or ENo 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 fora. 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: 17 (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@100') construction to the following:
10.Static water level below top of casing: 17 (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
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 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