GW1-2021-06798_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY: i
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. Opper I4;WATER
FROM TO DESCRIPTION
Well Contractor Name
NC3322-A
NC Well Contractor Certification Number -' .OUTER CASINO, forinulti=cased w01§ MLIT-ER if.a liclble.
FROM TO DIAMETER THICKNESS hiATER1.4L
Regional Probing Services ft. ft. in'.
Company Name 16'3NNEWCASING'Olt TlJ$LNG `eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 3 Fr. 2 i" sch 40 PVC
List all applicable nrll con,slruclion permits(i.e.C'ouno%Slate,Variance,etc.)
ft. tt. ip•
3.Well Use(check well use): Ii7.SCREEN
Water Supply Well:
TO DIAMETER _ SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 3 f`' 13 ft.
2 in 010 Sch40 PVC
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single)
$ GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 1 tt. cement grout pour
Non-Water Supply Well:
❑O Monitoring ❑Recovery 1 ft 1.5 {` bentonite; pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 34:SANI)/GRAVEL PACK if a' livable: - �7
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 2 ft 18 ft• #2 sand Prepack/pour
ft. ft. j
❑Experimental Technology ❑Subsidence Control
20.EiRMLING,LOG,'attach addittonalsheets if neces§ary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock h e,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 13 {t ! silty Clay
ft. ft.
4.Date Well(s)Completed: 6/24/2021 MW-1
5.Well Location:
la1°
Former Lucas/Connor Property
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
520 Jones Street, Wilson ft. ft.
Physical Address,City,and Zip
Wilson rt;a,0e1 t
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient) a Nsigne rwwrenceopper
:ON:cn=Lawrence Opcer,xaegional
35.719000 N -77.911114 W Lawrence Opper°Probingse ice=,ou, 7/12/2021
emas=larry�regionalprobing.com,c=1/5
Bate
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,!hereby certify that the u•ell(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 AND copy o this record has been provided to the well owner.
!/'this is a repair,fill out known well construction information and explain the nature ofthe
repair under N21 remarks section or on the back ofthis fbrm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages ifnecessary.
Por multiple injection or non-waler supply weNs ONLY with the same construction,van can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 13 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii&rent(example-3@200'and 2C100') construction to the following:
10.Static water level below top of casing: (ft.) Division of water Quality;Information Processing Unit,
If water/girl is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Ge0be DP above, also submit a copy of this form within 30 days of completion of well
ro
12.Well construction method: p construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,.Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Simnly&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit otie',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 G W-t North Carolina Department of Environment and Natural Resources—Division of water Quality Revised Jan.1013