GW1--00366_Well Construction - GW1_20240112

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. Opper ,1.WATER ZONES . . •' 'a. :/ _ "
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft.
NC Well Contractor Certification Number ',IS.OUTER,CASING-(for multi-cased wells):OR.LINER(if tip livable)a ' ,,
FROM TO DIAMETER THICKNESS fi 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. 18 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):
Water Supply Well: FROM • TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 18 fL 28 ft' 2 i"' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft t"•
❑Industrial/Commercial ❑Residential Water Supply(shared) a IL.GROUT ; '
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 3 ft• cement grout pour
Non-Water Supply Well:
IJMonitoring ❑Recovery 3 ft: 16 ft• bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation i19.SAND/GRAVEL PACK(if applicable) ;s l''A ,-
FROM TO MATERIAL EMPLACEMENT METHOD
['Aquifer Storage and Recovery ['Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 16 ft' 28 it #2 sand prepack/pour
It, ft. 1
DExperimental Technology ❑Subsidence Control
20:DRILLING LOG(attach additional"AWN if necessary) " ` ` -,°.`"k
❑Geothermal(Closed Loop) 13 Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) 0 ft• 0.5 ft• ! soil or crushed stone
4.Date Well(s)Completed: 11/16/2023 MW-9, MW-10 0.5 ft. 27 It tan-brn sandy Silt
. ft• 28 ft• Partially_weathred rock
5.Well Location: ft. ft. "- a ,.,� I i'd' 'i,"`,
Vicksboro Grocery& Grill ft. ft. 1 f� / -
Facility/Owner Name Facility IDII(if applicable) ft. ft JAN 1 v 2024
•
6215 Vicksboro Road, Henderson
ft. ft. 1n1..rrr nPr g:,n,gUnX.'
Physical Address,City,and Zip '2I.REMARKS ::%i •`. '" -i"->,-..`-:; .. .. 4!e's4ar:`i°vCI',_ ', s •;
Vance
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
1
(if well field,one lat/long is sufficient) Dlgnauy signed'by Lawrence Opper
-
36.305816 N 78.276550 W Lawrence Opper`ofl'binlarv@re,'''''probing. 12/11/2023
-- - - U./e.2022.12.1210.4553 05'00'
. Signature of Certified Well`Contractor I Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certt&thatthe well(s)was(were)constructed in accordance
with 1SA 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 ENo 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 1121 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: 2 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: 28 (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@100') construction to the following:
10.Static water level below top of casing: approx 22 (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 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.) • i
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-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013