GW1-2021-01786_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For mtemal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Lawrence D. Opper 14:WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
NC3322-A rt. ft.
C�, 15.OUTER CASING for mi1N cased wells OR L71�TER if a"`licabte
NC Well Contractor Certification Number V �5�p� FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services PQ� tom ,o� tt. ft. i"•
Company Name � 1 5 2 �rinaiTHIICKN S MATERIAL
0
iF6ROINNER CASING OR 1[TB NGE�Rh L
2.Well Construction Permit#: {.4 ft. ft. VC
List all applicable well construction permits(i.e.County,State,Variance,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 15 `t' 30 `t' 2 i" .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
❑lrri ation 0 ft' 3 ft• cement grout pour
Non-Water Supply Well:
OMonitoring ❑Recovery 3 rt. 13 `` bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19,SAND/GRAVED PACK'ifa licgbT ` -"
FROM TO MATERIAL' EMPLACEMENT METHOD
❑A uifer Storage and Recovery ❑Salini Barrier
q g ry ty 13 ft• 13 `t• #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.JDRiLLING LOG attach<addttiririalishe/•ts if rieeessa '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrock h q gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 30 ft Silty,Sandy Clay
`f `f
4.Date Well 2/24/2021 MW-8s)Completed: ft. ft.
5.Well Location:
Faison's Community Store Incident#06702
Facility/Owner Name Facility IDA(ifapplicable) ft. ft.
8799 Hwy 158 & NCHS East Rd., Conway 27876 ft. ft.
Physical Address,City,and Zip 21.REMARKS
Northampton
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification a�""ry g ed°" W2 aOpP"
ee
(ifwell field,one[at/long is sufficient) Lawre
aou„s smxes w,
Opper
36.44479 N 77.32462 W w.rvewamoa�em. 3/16/2021
Wte.11n I.U3.i6,31931-0CtlR
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By signing ihis form,1 hereby certify that the uell(s)itas(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 ❑No copy of this record has been provided to the well owner.
1f 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,vnii can
submit one forni. 24.Submittal Instructions:
9.Total well depth below land surface: 30 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiftrent(example-3@a 200'and 2C100) construction to the following:
10.Static water level below top of casing:
26 Division of Water Quail iy,:Information Processing Unit,
(ft.)
ff water level it above casing,use•'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4.5 (in.) 24b.For infection Wells: in addition to sending the fonn to the address in 24a
AU above, also submit a copy of this form within 30 days of completion of well
Auger 12.Well construction method: g construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gym) 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.
i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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