GW1-2023-02081_Well Construction - GW1_20230307

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 WATER ZONES
�p F FRROM TO DESCRH'TION
Well Contractor Name ft. ft.
NC3322-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased we11s OR LINER if a ficable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)
FROM 10 DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 5 ft. 2 in. sch 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc)
ft. ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft' 20 ft' 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. ft
Non-Water Supply Well: 3 cement grout pour
OMonitoring ❑Recovery 3 ft. 4 fL bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
4 ft 20 ff#2 sand pour
❑Aquifer Test ❑Stormwater Drainage -
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if neeess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain sim,etc.
❑Geothermal (Heating/Cooling Return) ❑other(explain under#21 Remarks) 0 ft- 20 ft tan-brn silty Clay
1/24/2023 MW-1 ft- 20 ft. Rock Refusal
4.Date Well(s)Completed: ft. ft.
5.Well Location: ft ft
Brewer's Grill & Grocery ft. ft.
Facility/(honer Name Facility ID#(if applicable) ft. ft. MAR 1.
11413 NC 42 East, Middlesex -
ft. ft.
Physical Address,City,and Zip 21.REMARKS _
Nash
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: /
22.Certification:field,one ladlong is sufficient) li Igitally,gned by lnwrence Opw,
DN:cn=e,rence Opper,o Regional
35.681900 N 78.212623 W Lawrence Opper °k-1ces,nalpmGg.com.c=DS 2/17/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): IZPermanent 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.02U0 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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 ONLY with the same construction,you can
submit oneform. 24.Submittal Instructions:
9.Total well depth below laud surface: 20 (ft.) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diiereni(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: approx 10 tit.) Division of Water Quality,Information Processing Unit,
/f water level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4.0 (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
132.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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013