GW1-2022-09946_Well Construction - GW1_20221031

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. O er a24 WATER
Lawrence u„g.'; t ,.r . .
pp FROM TO I DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft ft.
NC Well Contractor Certification Number 15.'OUTER CASING for"mill=cased-ivells Olt Lt}VEIY rfa hcalile
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name '16ANNEWCASIN9tORTUBING ibthirmal`closed
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 5 ft. 2 1n. SCh 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc)
ft. ft in.
3.Well Use(check well use): 17YSCiFiEEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 5 ft' 20 rL 2 1°' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.{
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT ,,,'"•'•
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri anon 0 ft. 3 ft. cement grout pour
Non-Water Supply Well:
IZMonitoring ❑Recovery 3 ft- 4 ft- bentonite pour
Injection Well: ft. tt
❑Aquifer Recharge ❑Groundwater Remediation 19.S)"1GRAVEGPAGK it-a" licstile r=. _
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4 ft• 20 ft. #2 sand Prepack/pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
-20.DRILLING:LOG attach addi6ortal'shaits;,ifneiessa �
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock type,grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 20 ft. Orange silty Clay over tan-brn silty Sand
ft. ft.
4.Date Well(s)Completed: 6/20/2019 MW-5,MW-6,MW-7 ,
ft. ft ELm. 5
5.Well Location:
ft. ft.
Earl's Service Center e. ft 2022
Facility/Owner Name Facility ID#(if applicable)
ft. ft. (jrr:l
3964 Raleigh Road, Henderson ft. ft. D
Physical Address,City,and Zip 21:REMARKS.E, ar .`: , ,• a
Vance
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(ifwell field,one latilong is sufficient) j;Dlgltalysgnedey�menceopper
Lawrence O er,on:rn awrenceoopper,a=aegbnal
36.277150 N 78.406339 W pp i PmblgServces, a 10/16/2022
—e''I,Wrry�reglon Iprobirg.com,c=US
Signature of Certified Well Contractor Date
6,is(arc)the well(s): 1OPermanent or ❑Temporary By signing this form,I 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 ElNo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under 421 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
8.Number of wells constructed: 3 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONI Y with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@I00') construction to the following:
rox
10.Static water level below top of casing: a pp 12 (ft.) Division of Water Quality;•7nformation Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,'Raleigh,NC 27699-1617
1L Borehole diameter: 4.25 (in.) 24b.For Infection Wells: In addition',to sending the form to the address in 24a
above, also submit a copy of this form;within 30 days of completion of well
robe Direct-Push
12.Well construction method: Geop 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&Geothermai 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 they county health department of the county
where constructed. �
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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