GW1-2022-03404_Well Construction - GW1_20220315

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. PP er ;F4,1�'ATER
FROM TO x DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A
NC Well Convector Certification Number
15:OUTER CASING for multi-cased wells OR LIME if i licable ,
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name
16.INNER CASING OR TUBING vothermal dosed loo '
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft' 5 ft' 1 i"' SCh 40 PVC
List oB applicable cell construction permits(i.e.County.State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): 17.•SCREEN. .
Water Supply Well: FROM TO DIAMETER .SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipa"ublic 5 "' 115 ft' 1 '"' .020 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 118:=GRO,UT_..
FROM TO MATERIAL_u EMPLACEMENT METHOD&A-MOUNT
❑Irrigation 0 ft. ft
Non-Water Supply well: 3 cement grout pour
❑OMonitoting ❑Recovery 3 ft- 4 ft- bentonite pour
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAfiti/GRAF);PACK ifs lic;ihte r .: ,,.... .
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 5 ft' 15 ft #2 Sand Prepack/pour
fi. ft.
❑Experimental Technology ❑Subsidence Control
2MDRILI INGi1 OG attacbaddt6otial sfieets if necessary ..,:
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock 41pe, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it 15 ft Silty Clay over Silty Sand
4.Date Well(s)Completed: 2/15/2022(MW-7R2022,MW-8R2022) ft. ft.
ft. ft.
5.Well Location:
Former Franklin Baking Sunbeam Terminal
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
410 South JK Powell Blvd.,Whiteville „
ft. ft. "a �. r ,"N V ,T',: r
Physical Address,City,and Zip
!21.REMARKS.. ..; .,
Columbus
County Parcel Identification No.(PIN) { f r f +
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification 'A"''"
(ifwell field,one[at/long is sufficient) wa;uyas dMu Muoace
-ore<=u,<—''. —o-',nm�
34.3252003 N 78.708108 LawrenceOpper 2/23/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this fain,I hereby certify that the wells)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 ElNo cow of this record has been provided to the web owner.
Ifthis is a repair,fill out known well construction information and urplain the nature of1he
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: 2 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 farm. 24.Submittal Instructions:
9.Total well depth below land surface: 15 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nwhiple wells list all depths ifdifjerent(example-3C200'and 2C100') Construction t0 the following:
10.Static water level below top of casing: _g (ft.) Division of Water Quality;Information Processing Unit,
1f water level is above casing.use"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.25 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Geoprobe DPT 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 one copy of this form within 30 days of
13b.Disinfection a Amount: completion of well construction to the county health department of the county
type: where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013