GW1-2021-02471_Well Construction - GW1_20210923

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
Regional Probing Services 14.avaTER ZONES.
FROM TO DESCRIPTION
Well Contractor Name
fit. ft.
3322-A
rt. rt.
NC Well Contractor Certification Number '15.OUTER CASING for multi-cased-wetIs OR Lllss'ER if a"livable
Regional Probing Services FROM TO DIAMETER THICKNESS MATERIAL
ft. in.
Company Name 1 n A 16.INNER CASING OR TUBING eot8`erma]closM-loop)
2.Well Construction Permit#: y n I M0701 252 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.II/C,County,State, Variance.etc) 0 fit. 2 fit. 1 in.
3.Well Use(check well use): fit. ft. in.
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOTSIZE THICKNESS NIATER14L
❑Agricultural ❑Municipal/Public 2 ft. 12 rt. 1 in. :010 1 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 2 ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt 1.5 ft- Bentonite' Pour
OMonitoring ❑Recovery ft. ft.
Injection Well:
fit. fit.
❑Aquifer Recharge ❑Groundwater Remediation
19::SAND`/GRAVE1 PACK if.e` livable;
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 1.5 R• 12 ft' No 2 Sand Prepack/Pout
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLINGLtlG attacb aadidofiateets if neeessary -
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION',(color,hardness,soiVrock type,grain size,etc.)
0 rt 12 rt Silty,Clayey Sand
4.Date Well(s)Completed: 8/14/2021 Well iD# TW-1'TW-2 ft. rt.
Sa.Well Location:
NCDEQ DWM IHSB
Facility/OwnerName Facility lD#(if applicable) ft. ft.
2001 Neuse Blvd., New Bern rt. rt. sing Uri
Physical Address,City,and Zip rt. rt. Inl3f^•3 edOn
Craver) 21sREMARKS ;.
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.11123507 77.06706851
N W Lawrence Opperw 9/6/2021
6.Is(are)the well(s): ❑Permanent or InTemporary Signature of Certified Well Contractor Date
By.signing this form,/herefiv centyy that the wcll(.c)was(were)construe ted in accordance with
7.is this a repair to an existing well: ❑Yes or 19No 15A N(AC 02C•.0100 or 15A,NCAC 02C 10200 Well Construction Standards and that a copy
I/this is a repair,fill out known well construction hybrtnation and explain the nature of the qJ this record has been provided to the well onwer.
repair under 1121 remarks section or on the hack q'ihis fibrin. -
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12 (fit) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths il'diljerent(example-3@200'and 2C100')
3 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1(n•ater level is above casing.use"-i-•'
II.Borehole diameter: 3.25 (in,) 24b.For Injection Wells:Copy tojDWR,Underground Injection Control(IUC)
Program.1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Geoprobe DPT i
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing Iver 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018