GW1-2021-07952_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. Opper J4.�tATERZOr�s;
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A
NC Well Contractor Certification Number
l�OUTER CASING'for:inulti cased welts:OR'L1NER rf a""'livable .=' rQ
FROM TO DIAMETER MATERIAL
Regional Probing Services ft. ft. in.
Company Name
116.41yNER'CASING OR`C[TBLNG etither'thal.etoseit-too x" � .-,
FROM I TO I DIAMETER I THICKNESS J•/ATER[AL
2.Well Construction Permit#: 0 ft. 2 ft. 12 in. seh 40 PVC
List all applicable well construcvion permits(i.e.C'ounty,State,Variance,etc.)
in,
3.Well Use(check well use): I7.SCREEl1 ��• ,
Water Supply Well: FROM TO DIAMETER I SLOTSIZE ITHICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 tt' 12 ft 2 i"' I i .010 SCh40 I PVC
❑Geothermal(Heating/Cooling/Coolin Supply) ❑Residential Water Supply ft. ft. in.
( g g PP Y) PP Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROU3 - ) ;_„
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 1 ft. cement grout tremie
Non-Water Supply Well:
❑Monitoring ❑Recovery 1 ft. 1,5 ft• bentonite' prepack
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation I9:'SAND/GRAVEL PACK Oti"ullcable:it
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. fa #2 sand Prepack/pour
1.5 12
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:;DRILL7NG,LOG attach Addrhonat glieets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock h• e,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 f�' 12 ft tan-brn silty Sand
4.Date Well(s)Completed:
7/1/2021 MW-14
ft. ft.
5.Well Location:
Former JDE#5 .�
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. A
1784 Wilmington Highway, Jacksonvilletll.
cessing UI
Physical Address,City,and Zip 21:=22EMARI S,., "' ' w' l
12
Onslow
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one]at/long is sufficient) 0 gft0yslgne ytawren<eopper
Lawrence Oppe `n-Lawence Opp,o=aegional
34.739049 N 77.464603 ProbingSemi<e, 7/14/2021
...Bate•
m�i' anrlbnalrbing.corn,c=US
..o.-.oAi.eg rr;po3W1 86•Bg'
Signature of Certified Well Contractor Date
6.Is(are)the wetl(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NC4C 02C.0100 or 15A NCAC 02C.0200 Wcll Construction.Standards•and that a
7.Is this a repair to an existing well: ❑Yes or END copy gflhis record has been provided to the tell owner.
If this is a repair,fill out known well construction in formation and explain the nature of the
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 same construction,you can
submit one 16rm. 24.Submittal Instructions:
9.Total well depth below land surface: 12 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii&rent(ezannple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: approX 4 (ft) Division of Water Quality;,Information Processing Unit,
11"water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 4.25 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
AU - DP 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
(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(gpm) Method of test:. 24c.For Water Supply&Geothermal Wells: In addition to sending the foam 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-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
i
i