GW1-2021-03381_Well Construction - GW1_20210607

I
WELL CONSTRUCTION RECORD For I ntemat Use ONLY:
This form can be used for single or multiple wells
r
1.Well Contractor Information:
Lawrence D. Opper 14,'A'ATERZONES
FROM TO DESCRIPTION
Wei I Contractor Name
NC3322-A
NC Well Contractor Certification Number 15.OUTER CASING for mutt'<asedwells.OR L1NER,if a eatable
FROM TO DIAMETER' THICKNESS MATERIAL
Regional Probing Services ft. rt. in:
1&4NNER CASING OR TUBl[IG .eothermal closed too
Company Name
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 2 ft. 2 i" I Sch 40 1 PVC
List all applicable well construction pennies(i.e.County,Slate,Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 f`' 12 ft' 2 in. .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 EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 1 f�• cement grout pour
Non-Water Supply Well:
17Monitoring ❑Recovery 1 rt. 1.5 ft. bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL'PACK ifa licatile
E4
FROM TO MATERIAL EM 11 P 11 LACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 1.5 f`' 12 f`' #2 Sand Prepack/pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG fattaeli additioital�heets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillmck type,g=sire,ete.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f`' 12 f` Silty Sand over hard Sandy Clay
ft. tt.
4.Date Well(s)Completed: 4/25/2021 MW-2,MW-3,MW-4
ft. ft. I
5.Well Location: LJ
Mt. Airy Superette (Former) rc. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft X
6627 NC Hwy 72, Pembroke
n Unit
Physical Address,City,and Zip
21.REN1A13K5
Robeson D '
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification.
(ifwell field,one[at/long is sufficient) Digl+xllyslgned by Lawrence Opper
ON:cn=Lawrence 0pper,e=Reglonal
34.683562 N 79.136785 W Lawrence Opper'ProbingSewke,•op. 5�2oi2o21
einaildarrya�reglonalprobingm ,c=US
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certiJ}'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 FIN0 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 o he
repair under#21 remarks section or on the back of this farm. 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
submil 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
Far multiple wells list all depths ifde (example-3m00'and 1C100� construction to the following:
10.Static water level below top of casing:
approx 2 Division of Water Quality,Information Processing Unit,
(ft.)
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter.• 4.25 (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
auger-DP
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 farm to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction toy the county health department of the county
where constructed. I�
f
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
f � I
i
h
I