GW1-2021-03229_Well Construction - GW1_20210624

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. O er 14.WATER ZONES .'1
PP FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A
NC Well Contractor Certification Number 45.OUTER CASING fdr'.iriulii eased ivclls ORLINE&tf a 'ticabte
E6.INNER
TODIAMETER THICKNESS MATERIAL
Regional Probing Services ft. tt.CASING OR`'TUBIN('. eothetirial close?tooCompany Name TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft' 5 ft. 2 in• sch 40 PVC
List all applicable well construction permits(i.e.C'ounty,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): EENWater Supply Well: TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 20 ft. 2 i" •010 1 Sch40 I PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18;GROUT r
PDRILL
TO MATERIAL EMPLACEMENT METHOD&A.MOUNT
❑Irri ation 3 ft. cement grout pour
Non-Water Supply Well:
OMonitoring ❑Recovery 4 ft- bentonite pour
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation GRAVEI°°PACK;if a" 7icabl'e, -„,
TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 20 ft' #2 Sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft.
❑Experimental Technology ❑Subsidence Control
fiVG'LOG:iidach additional'sheets if uecessa :::
❑Geothermal(Closed Loop) ❑Tracer TO DESCRIPTION color,hardness,soiVmck h rain site,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) - 20 ft• tan-bm silty Sand
5/25/2021 MW-1A '4.Date Wells)Completed: .5.Well Location: . ft.
RECEIVED
Scotchman 3105
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
201 E. Fayetteville Hwy., Roseboro
ft. ft.
Physical Address,City,and Zip
21,RENIARKS
Sampson
County Parcel Identification No.(PM)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one ladlong is sufficient) yi "19.edbywwan<eoPx,
N:en=tawrenee 00w,oReloml
34.956809 Lawrence eo 6/11/2021
N W am�9aP„bn9Oe_U5
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this firm,/hereby certif}°[hcr!'the wr//(s)ans(were)constructed in accordance
with 15A NCAC 02C.0/00 or 15A NC AC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy ofthis record has been provided to the well owwei:
/fthis is a repair,fill out known well construction information and erplahn tine nature of the
repair under 421 remarks section or on the back gfthis 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.
Far multiple injection or non-water supply wells ONLY with the same construction,van can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(example-3©200'and 2C100� construction to the following:
10.Static water level below top of casing: a pprox 12 (ft.) Division of Water Quality,Information Processing Unit,
/fwater leixel is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: 3.25 (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
12.Well construction method: Auger- DP construction to the following: f
(i.e.auger,rotary,cable,direct push,etc.) f
Division of Water Quality,Undergroundlnjection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test: 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit dne 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 G W-I North Carolina Department of Environment and Natural Resources—Division of Water Qua Ility Revised Jan.2013