GW1--00319_Well Construction - GW1_20240112

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER=ZONES
Lawrence D. Opper FROM TODESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft. f
NC Well Contractor Certification Number .IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. ;in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)'.
. FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft. 1 ' 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 5 ft 15 ft' 1 1n. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. .
GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.ed) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft. cement grout pour
Non-Water Supply Well:
lMonitoring ❑Recovery 3 fr. 4 ftbentonite pour
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) ' - : '
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 fr. 15 rc• #2 sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) _
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fc. 15 ft• Silty Clay and Sand
11/20/2023 ft. ft. �
4.Date Well(s)Completed: ft. IL 6 ;'� f 1m f )
5.Well Location: ft. ft.
Enfield Timber ft. ft. ; JAN 12 2024
Facility/Owner Name Facility iD#(if applicable) ft ft. f �cc., n '> A ( p�
1n par,f i n t rocwz;..1 U
21144 US Hwy 301, Enfield ft. ft. WV'c (...14.5
Physical Address,City,and Zip
Halifax
County Parcel Identification No.(PIN) j
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(if well field,one lat/long is sufficient) S W :7 0;"'''''byocl
w„a,uopoc,
oK1,,.,�
36.154154 77.693913 Lawrence Opp
� S 11/30/2023
N wle2023.113 0 17343 0-Osw
Signature of Certified Well Contractor I Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo 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: 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 one form. 24.Submittal Instructions:
9.Total well depth below land surface: 15 . (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@200'and 2@I00) construction to the following:
10.Static water level below top of casing approx 6 (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
above, also submit a copy of this form within 30 days of completion of well
direct-push
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 tojthe 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