GW1-2021-02577_Well Construction - GW1_20210923

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.1VATER ZONES u
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER if a'''licable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name KANNER CASING OR Ti3BLNG eothermal closed-loop)FROM TO DIAMETER , THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 2 tt. 2 1O• SCh 40 PVC
List all applicable sell construction permits(i.e.C'ounllt Stale,Variance,etc.) ft. ft. in. ,
3.Well Use(check well use): 17-SCREEN s
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft• 12 ft' 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
i
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
FROM TO MATERIAL L_ EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 rt. 1 f[. cement grout pour
Non-Water Supply Well:
❑+Monitoring ❑Recovery 1 ft. 1.5 ft- bentonite pour
Injection Well: f[. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19..SA19D1GRAVELAGK'ith �ttable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
1.5 fr• 12 fr• #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage tt. ft.
❑Experimental Technology ❑Subsidence Control 20•'DRILLiNGVLOG jattach additional4hSeets it necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type, rain sim,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 12 ft• Silty Clay over tan-brn silty Sand
8/23/2021 MW-25 rt. rt.
4.Date Well(s)Completed:
5.Well Location:
Pantry#922 rL rt:
Facility/Owner Name Facility ID#(if applicable)
-
2101 Wayne Memorial Drive, Goldsboro ft. ft. Wrc.
ces t
Physical Address,City,and Zip 21.REMARKS ,alort
v
Wayne
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one ladlong is sufficient) aaly:gnee by Wwrenre opper
DN:cn=Lawrence Opw o=aegional
35.398144 N 77.96486568 W Lawrence Opper en; �, ionalprobingtom,c US 9/13/2021
Signature of Certified Well Contractor Date
6.is(are)the well(s): ©Permanent or ❑Temporary Hy signing this form,1 hereby cerifi•that%the Ice/1(s)was (were)constructed in accordance
with 15A JVCAC 02C.0100 or 15A 1VCAC 02C.0200 If'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy nflhis record has been provided to the ivell owner.
fflhis is a repair,fill out known well construction info rniation and explain the nature uifthe
repair under 1121 remarks section or on the hack of lhisJiwni. 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 infection or non-water supply wells ONLY with the same construction,you can
submit one)ornt 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
Far multiple wells list all depths ifd event(example-3Ca,200'and 1C100') construction to the following:
10.Static water level below top of casing: approX 6 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing.use"4 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4.25 (in.) 24b.For Infection Wells: In addition'to sending the font to the address in 24a
Auger-DP above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 tone 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. j
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013