GW1--07566_Well Construction - GW1_20231121

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells i
1.Well Contractor Information:
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name ft. ft. l
NC3322-A ft. ft.
NC Well Contractor Certification Number IL OUTER CASING(formulti-cased;wells)OR LINER(if applicable)'
• FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services - ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) ' -
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 2 ft. 2 I in' sch 40 PVC
List all applicable well construction permits(i.e.County,Stale,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 2 ft. 12 ft 2 1°' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) °
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft.
Non-Water Supply Well: 1 cement grout pour
OMonitoring ❑Recovery 1 ft. 1.5 it bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
FROM _ TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier • 1.5 ft 12 ft #2 sand Prepack/pour
ID Aquifer Test ❑Stormwater Drainage ft. - ft.
❑Experimental Technology ❑Subsidence Control '20 DRILLING LOG(attach additional sheets ifnecessa ry)' °
❑Geothermal(Closed Loop) 0 Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2I Remarks) 0 it 12 it Silty Sand over hard Sandy Clay
ft. ft.
4.Date Well(s)Completed: 10/15/2023 MW-1R,MW-2R,MW-3R
ft. ft. ,
5.Well Location: ft. ft., y j~tl
Mt.Airy Superette (Former) ft. T
Facility/Owner Name Facility ID#(if applicable) (� 1
ft. ft. NOV 6 (_ Zt12J
6627 NC Hwy 72, Pembroke
ft. ft. ^ ice. t
Physical Address,City,and Zip
Robeson i
County Parcel Identification No.(PIN) /`
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: `,e
22.Certification: Dlgltalysigned by Lawrence Opper
(if well field,one lat/long is sufficient)
DM:cn=Lawrence Opper,mRegional
34.683562 N 79.136785 W Lawrence Oppe.r turn so regfo alpohlg.comr-US 11/6/2023
Date.2021.02.11 1531.49 0500'
Signature of Certified Well Contractor I Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby cert fy'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 IJNo 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
8.Number of wells constructed: 3 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 one form. 24.Submittal Instructions:
9.Total well depth below land surface: 12 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((dierent(example-3 tt 00'and 2@100') construction to the following: ' '
10.Static water level below top of casing: approx 4 (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: 4'5 (in.) 24b.For Injection 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: 1,
(i.e.auger,rotary,cable,direct push,etc.) I '
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: ' 1636 Mail Service tenter,Raleigh,NC 27699-1636
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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. I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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