GW1-2021-03066_Well Construction - GW1_20210624

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor information:
er 14.WATER ZONES
Lawrence D. O
pp FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A f` ft• 1
NC Well Contractor Certification Number 1S.'OUTER CASING far tt)ulti cased w 11s OR3;TNER if a `licable ;•
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name 16.INNER CASING OR TUIIING, eoth'Ermal closed 110
FROM TO DIAMETER. THICKNESS MATERIAL
2.Well Construction Permit#: 0 tt. 10 ft- 2 in. Soh 40 PVC
List all applicable well construction permits(i.e.C'ounty.State,Variance,etc.)
tt. ft. kin.
3.Well Use(check well use): 17.'SCREEN "
Water Supply Well FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
'"'
❑Agriculnlral ❑Municipal/Public 10 f`' 25 f`' 2 i `.010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S GROUT,
FROM TO M ATERIAL I EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 3 ft. cement gout pour
Non-Water Supply Well:
laMonitoring ❑Recovery 3 ft. g rt. bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation19.SANDICRAVEL.PACK?fis"livable : _..� _ _.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
9 It. 25 f`• #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LoG'attach additionalsheeis if necessa '"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soitfrock type,gmin sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f`' 25 ft• Orange silty Clay over tan-bm silty Sand
4.Date Well(s)Completed:
6/1/2021 MW-4R
ft. ft.
i
5.Well Location: REGLIVt
Pantry 176 ft, ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. J U N
208"Main Street, Clayton ft. ft.
1
Physical Address,City,and Zip u,w
'2i:-12EN1ARKS
Johnston "'
County Parcel identification No.(PiN)
i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one]at/long is sufficient) i D u Igneawtawanceopar
'DN: =la�nence Opper,o=aeglbnal
35.6520593 N 78.458092 W Lawrence Opper`p'-b-S.M'< o.,, 6/8/2021
-e'mall=larry2,reg(onalprobing.mm,c=US
;, wa�-ease'
Signature of Certified Well Contractor Date
6.Is(are)the wetl(s): ©Permanent or ❑Temporary By signing this form,i hereby certify that the trell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A A'CAC 02C•.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EINo copy gfthis record has been provided to the uetl owner.
/fibis is a repair,fill out known well construction information and explain the nature gfilre
repair tinder#21 remarks section or on the back gl'tbts fcum. 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 infection or non-water supply wells ONLY with the same construction,you can
submit oneform. 24.Submittal Instructions:
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(exaaple-3 200'and 2C,100') construction to the following:
10.Static water level below top of casing: approX 20 (ft) Division of Water Quality,Information Processing Unit,
If water lei-el is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.25 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Ge0 be above, also submit a copy of this foriti within 30 days of completion of well
12.Well construction method pro construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Undlrgrounddnjection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) Method of test:. 24c.For Water Supply&Geothermal 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 Environment and Natural Resources-Division of Water Quality) I Revised Jan.2013