GW1--02607_Well Construction - GW1_20240426

•
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
""
Lawrence D. Opper I4.WATER ZONES FROM TO DESCRIPTION
Well Contractor Name ft. ft.
'
NC3322-A ft. ' ft.
NC Well Contractor Certification Number .15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER I • 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. 3 ft. 2 1°• sch 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.) - -
ft. ft. in-
.
3.Well Use(check well use): I7:,SCREEN'.
Water Supply Well: FROM - TO DIAMETER SLOT SIZE THICKNESS MATERIAL__
❑Agricultural ❑Municipal/Public 3 fr.' 17 ft 2 1°' .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 EMPLAC EM ENT METHOD&AMOUNT
❑Irrigation 0 ft' 1 ft. Cement pour
Non-Water Supply Well: -
I�JMonitoring ❑Recovery 1 ft. 2 ft. #20 Bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)r
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 2 fr. 17 ft #2 sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft. ,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. .5 rt. Concrete
4.Date Well(s)Completed: 3/14/2024 MW-1A .5 it14 ft. brown f-c sand
ft. ft.
5.Well Location: ft. ft. F.? ""';, '.t a7-,v 9a„
Shallotte Family Fare BP#418 ft. ft. •-"
Facility/Owner Name Facility ID#(if applicable). ft. ft.4585 Main Street, Shallotte ANK ° G ZUZ4
ft. ft.
Physical Address,City,and Zip y�r.. '� �M t r3`
21,REMARKS :,>, ... .,,,
Brunswick
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification-
(if well field,one lat/long is sufficient)
33.97835131 N 78.377283500 W Lawrence Oppe, • P -- 3/27/2024
Signature of Certified Well Contractor 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 IZINo 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 constructions,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 17 (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: i
10.Static water level below top of casing: approx 5 (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: 3.25 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Au er, Geo robe above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g p construction to the following: 1
(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. 1
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013