GW1-2023-02082_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:
m 14.WATER ZONES,"
Lawrence D. Opper FROM TO 1 DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. f,
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased>wells AR LINER if a 6cable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. & I in.
Company Name -16.INNER CASING:ORTUBING getithermalclosed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 7 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 7 ft" 22 ft" 2 in. .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 ation 0 ft' 3 ft• cement grout pour
Non-Water Supply Well:
❑Monitoring EIRecovery 3 ft" 6 iL bentonite pour
Injection Well: ft. ft..
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
."
❑Aquifer Storage and Recovery ❑Salinity Barrier MATERIAL EMPLACEMENT METHOD
FROM TO
6 ft• 22 ft. #2 sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
?20.DRILLING LOG:attachadditiooal`sh"if necessa
❑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. 0.5 ft. Pavement over crushed stone
4.Date Well(s)Completed: 12/5/2022 -12/8/2022 0.5 ft" 22 ft. Inter bedded Silt,Sand and Clay
ft. ft.
5.Well Location: ft. ft.
Jacksonville Fleet Maintenance
ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 1qAR r
350 South Marine Blvd. , Jacksonville
Physical Address,City,and Zip 21.'REMARKS t , .,
Onslow IR Wells: IR-2,3,4,5,6,7,8,10,11,13,20,21,22,
County Parcel Identification No.(PIN) 22,23,24,28,29,30,31,32,34,35,36,37
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) Igita red by Lawrence Opper
N:cn=lawrence OpNr,aRegional
34.754772757 0.
N 77.447521 W Lawrence Opp�'':ma;klasry@regI naipmbing.com,c=US 12130/2022
Signature of Certified Well Contractor 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 23No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well constriction 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
8.Number of wells constructed: 24 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: 22 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 r200'and 2 rr 100') construction to the following:
10.Static water level below top of casing: approX 9 (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
Geoprobe DPT 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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013