GW1-2023-00458_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
1_WATFWZONES .
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name ft. ft.
r
NC3322-A ft. ft.
NC WellConhactorCertificationNumber ;15.�OlTGERCASiNG formuW-cased wells OR<LINER ifa"`Lcable -;
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft.. ft. in,,
"I6.INNER,CASINGORTUBING eotberinal'd6sedloo
Company Name FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 3 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 a,`:`•
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 ft 13 ff 2 'n" 010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPtY(single) ft. ft I in.;
❑Industrial/Commercial ❑Residential Water Supply(shared) A&GROUTS
FROM TO - MATERIAL' EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 1 ft• cement grout pour
Non-Water Supply Well:
1 rr. 2 fr. bentonite pour
OMonitoring ❑Recovery
Injection Well: ft: ft.
❑Aquifer Recharge ❑Groundwater Remediation A9.SAND/GRAVEL PACK,ifa ticabtu ,. �:
FROM TO MATERIAL, EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fi- ft.
2 13 #2'sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft. -
❑Experimental Technology ❑Subsidence Control
20.°DRILliING LOGY attacfi`additi6mdJsIieets ifneeess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVrock type,grain size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 13 ft. Stiff Clay
11/8/2022 MW-1 ft. f`.
4.Date Well(s)Completed: ft
5.Well Location: ft. ft.
Former Archer's Grocery ft. ft. JAN 0 9 "Z D
Facility/Owner Name Facility ID#(if applicable)
ft. ft
1208 NC Hwy 561 East Cofieldft. "- Y' "` �"'`�``";
i.J�'lSe k�1i�i+'
Physical Address,City,and Zip a
21:REMARKS..:ti�
Hertford
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: Di rail i nedb wrenceo
{, 9i YP9 Y PPer
j DPL•—awrence Oppee a=Regional
36.281492 N 76.872046 W Lawrence Opper ema ngse�,exoa, 12i4i2022
16-tarry@region Ipwbing.com,aUS
Signature ofCertified Well Contractor I' 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 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 of this 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#21 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLYwith the same construction,you can
submit oneform. 24.Submittal Instructions:
9.Total well depth below land surface: 13 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: approX 5 (ft) Division of water Quality;Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Geobe DPT above, also submit a copy of this ifoirm within 30 days of completion of well
ro
12.Well construction method: p 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 Sunnly&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 toll the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013