GW1-2022-09947_Well Construction - GW1_20221031

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
t
Larry Opper "KWATERZONEs
ft
Well Contractor Name FROM TO ft DESCRIPTION
NCWCC#3322-/� 3 12 first water bearing zone
ft ft
NC Well Contractor Certification Number
"I&OUTER CASING for multi-cased wells OR LINER,rf;a'°'livable
Regional Probing Services FROM TO DIAMETER THICIQVESS MATERIAL
ft ft. in.
Company Name
W I►A Q A6.1NNER CASING'OR TUBING' eott et•`inal dosed-joii
2.Well Construction Permit#' Mo 7/ 0 v FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,'etc.) O ft a ft ,S ra tl.yO P L
3.Well Use(check well use): ft ft. in.
e : 17 SGEN 3`•
Water Su
pp1 y Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural E]Municipal/Public 2 ft- 12 fL 0.75 in. 0.01 inch I PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.'(;ROIIT
rllffigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft 1 ft. bentonite pour
L)JtMonitoring DRecovery ft ft
Injection Well:
ft ft.
_ Aquifer Recharge Groundwater Remediation P
19:`SAND/GRAVET AGIC`if a" "lira` e .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage 1 ft 12 ft- #2 sand pouring down borehole
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) Tracer 2U:bR[LLING.I 0 attach additional Wheels ifnec'essa
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil rock type,grain size,etc.
ft ft- See attached
4.Date Well(s)Completed:09/28/2022 Well ID#TPMW 1-5 ft ft.
5a.Well Location: & ft.
Khai Le ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft. � 4•,..s
57 US Highway 64 E, Plymouth, NC 27262 ft ft. 00T
Physical Address,City,and Zip ft ft.
Washington 6767853340 �2IVREMARKS
County Parcel Identification No.(PIN) Temporary wells. Abandoned the sarr9'd' 4PAerrtb &a
PVC and backfilled boring with bentonite.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.85917 N 76.74417 w
10/13/2022
6.Is(are)the well(s)> Permanent or x)Temporary Signature of Certified Well Contractor N Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or )No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:5 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:3 to 3.3 (ft) Division of Water Resources;Information Processing Unit,
If water level is above casing,acre"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:2.25 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
direct push above,also submit one 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 Resources,Un h derground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test: 24c.For Water Supply&Infection 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.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016