GW1-2022-01129_Well Construction - GW1_20220103

WELL CONSTRUCTION RECORD For Internal 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
We]I Contractor Name ft. ft.
NC3322-A
1
NC Well Contractor Certification Number 15.,OUTER CASING for multi-cased wells OR LINER ifi 'ticable
FROM TO DIAMETER THICKNESSI MATERIAL
Regional Probing Services ft. ft. in.
16.INNER CASINGOR TUBING. eofhei•mal closed-loo
Company Name '
WM0701263 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 f`• 32-36 f`• 1.25 "i"• Steel
List all applicable well construction permits(i.e.C'ounty,57ate,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 32-30• 36-40 f`• 1 in. .010 Stainless
❑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
❑irri ation ft. ft.
Non-Water Supply Well:
ft. ft.
OMonitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK:if'a uiab101
x, „_. ...._.
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
silty sand Natural Formation
❑Aquifer Test ❑StotmwaterDrainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
+,20.­I)RILLING'LOG'attachs$dt66iiah'shieefs-if
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,son/rock h•e,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f` 36 f` silty sand
4.Date Well(s)completed: 11/17/21-11/18/21 rt, 40 f` silty sand
ft, ft.
5.Well Location: ft. ft.
Former Stanadyne Facility ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
230 Clarks Neck Road, Washington ft. ft. Jq
Physical Address,City,and Zip 21.REMARKS.
Beaufort 556-94-1374 DPT Groundwater samples collected @ 24'an ymm�, io s �
County Parcel identification No.(PiN) DPT Groundwater samples collected tWA
b n.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification
(ifwell field,one lat/long is sufficient) Dlgltalyslgn wan eoppe
ON:cn=tawren<e Opper,maegiaml
35.5622 N 77.08420 W Lawrence Opper°Frohing5evices,aa, 12/3f2021
emSU=Jarry,�reglonalprobingmm,r-US
Signature of Certified Well'Contractor Date
6.Is(are)the well(s): ❑Permanent or 10Temporary by signing this form,1 hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction,Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under i121 remarks section or on the back of this farm. 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: 5 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,Zara can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 36-40 tft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudriple wells list all depths ifdii fferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: approX 10 (ft) Division of Water Quality,Information Processing Unit,
If water lcmel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1.5 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Geo robe Direct-Push above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: p 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(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
136.Disinfection type: Amount completion of well construction to Ae county health department of the county
where constructed.
i
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Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013