GW1-2022-08963_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information:
14,WATER ZONES
_.
Lawrence D. Opper FROM TO DESCRIPTION
Well Conti-actor Name
ft. ft.
NC3322-A ft. ft
NC Well Contractor Certification Number •15.OUTER CASING for malt*-cased wells OR LINER if a licablc
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services & ft. in.
Company Name '16:INNER CASING OR TUBING geothermal closed400
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 20 ft- 2 in. sch 40 PVC
List all applicable well construction permits(i.e.County,State,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 20 ft' 35 ft' 2 t"' 1 .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) xg•`GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. ft
3 cement grout pour
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft. 18 ft- bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK 0 applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 18 ft 35 ft. #2 sand pour
ft. ft.
❑Experimental Technology ❑Subsidence Control `20.'DRILLING LOG attach additionalsheets if netessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,soil/rock typi,,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 35 ft• tan-brn silty Sand with interbedded clay
8/18/2022 MW-1,MW-2,MW-3 ft. fL �y� , - 'rt 111F---;--'-
4.Date Well(s)Completed: ft. ft. IL—S tt 6-,,,L-F
5.Well Location: ft. ft. S t P 1 n 2022
Hertford County School Bus Garage ft. ft.
Facility/Owner Nanre Facility ID#(if applicable) ft. ft. n"��" 5' n-~ W W a ' a
701 N. Martin Street, Winton D"�'0MO''
ft. ft
Physical Address,City,and Zip 2L:REMARKS,'f ,
Hertford
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificatio
(ifwell field,one lat/IDng is sufficient) �Digitally signed by aw ence Opper
DN:—Lawrence Opper,o=Reylonal
36.3983991 N 76.9350155 W Lawrence Opper emek ry@reg°nx,pob;ng.com, DS 9/8/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)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 ❑No copy afthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#11 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 3 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. 24.Submittal Instructions:
9.Total well depth below land surface: 35 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: approX 28 (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: 3.5 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
GeOprObe 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 type: Amount: completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of water Quality Revised Jan.2013