GW1-2022-03406_Well Construction - GW1_20220315

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor information:
14.WATER ZONES
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name
NC3322-A
NC Well Contractor Certification Number I5,'OUTER CASING for malti-cased wells OR LF ER if a licable
FROM TO DIAMETER 1 THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name '16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 2 ft- 2 SCh 40 PVC
List all applicable well construction permits(i.e.County.,Slate.Variance,etc.)
ft. ft. fin.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER :SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 f`' 12 R• 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ]$•'GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. ft.
Non-Water Supply Well: 1 cement grout pour
0Monitoring ❑Recovery 1 f`' 1.5 ft bentonite pour
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL'P.ACK(its' licabl'g'FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
1.5 ft- 12 f`• #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG.attach=additional ibeets'if necessary),,*'.
❑Geothermal(Closed loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil rock q e,imain sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt 12 ft tan-brn silty Sand
4.Date Well(s)Completed:
2/14/2022
ft. ft.
5.Well Location:
Circle K 2723122
Facility/Owner Name Facility ID#(if applicable) ft. ft.
6480 Market Street, Wilmington
Physical Address,City,and Zip „21 REMARKS
New Hanover
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) o I signed by awrence Opper
ON:cn=lawrenm'Opper.o=Regiomi
34.255793 N 77.841782 W Lawrence Opp&P,obingsen,i� ,0U, 3i3/2022
erYi5i1>larrygreglonalprobing.mm,-US
Signature of Certified Well Contractor Date
6.is(are)the well(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 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy ofduis record has been provided to the well owner.
117his is a repair,fill out known well construction information and"plain the nature ofthe
repair under 1121 remarks section or on the bock of thiform. 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,ymt can
submit one form. 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
hbr multiple wells list all depths i#'dii fereni(example-3@200'and 2@100') construction to the following: -
10.Static water level below top of casing: approX 6 lft) Division of Water Quality,Information Processing Unit,
If wafer level is above easing.use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4.25 (in.) 24b.For infection Wells: In addition to sending the form 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
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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 the county health department of the county
where constructed. 4'
Form G W-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013