GW1-2022-08335_Well Construction - GW1_20220502

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. O er ���Y4,�w, RZQN PTI .PP FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft.
NC Well Contractor Certification Number e15"D RiD� � W"kIli.c�'sed�vehs OTLIt1ER if's—lieabte
FROM TO DIAMETER In. THICKNESS MATERIAL
Regional Probing Services ft. ft.
Company Name 416YINNEWCASINGOft TUBING`eofhertnahctosed loa
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 5 tt. 2 in. Soh 40 PVC
List all applicable uc//constr ction permits(i.e.Counly,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 5 ft' 20 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential WaterSupply(shared) "BGROi17�
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 2 ft cement grout pour
Non-Water Supply Well:
Monitoring DRecovery 2 ft- 3 ft- bentonite, pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation :JSift?RA�' 'AiCKi ii 1161 FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 3 tt. 20 ft' #2 sand Prepack/pour
❑Aquifer Test ❑StormwaterDrainage f"t. ft.
❑Experimental Technology ❑Subsidence Control
�Q:DR11I:'ING .Attdch eildrtlonaT'IFe�etsatf tiece"s3'a ��?.- '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness soil/rock type,gnin sir etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 20 ft• silty Clay over silty Sand
4.Date Well(s)Completed:
2/21/2022 MW-1 ft. it•
ft. ft.
5.Well Location: ft. ft.
401 Cleaners DSCA DC350001
ft. ft. ..
Facility/Owner Name Facility IDt!(ifapplicable) ft. ft.
608 n. Bickett Blvd. Louisburg ft. ft.
Physical Address,City.and Zip
Franklin
LEMA,RKS,_County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification.
(ifwell field,one lat/long is sufficient) f D19aa1lys1gnedby Lawrence Dpper
, e:- w.t.K41oDn7arp2
1p9pe.9rp9bx-0mqIat.ec16gp'm
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36.1045510 N78.292353 Lawrence OPP r,f1hn9r,,e;p =US 3/17/2022--- -------
Signature of Certified Well"Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary y g f y h (J
B signing this form,I lrereb•curt!`that the well s inns 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 ElNo copy of this record has been provided to the ale//owner.
If this is a repair,fill out known[tell construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis./orm. 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 ntulliple injection or non-water supply wells ONLY with rile same construction,you can
suhmir 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
h'or mnlliple wells list all depths ifdierent(example-3Q200'and 2@100) construction to the follovavmg:
10.Static water level below top of casing: approx 12 (ft) Division of Water Quality,Information Processing Unit,
I/'water lcn•el is above casing.use"+" 1617 Mail Service Center,Raleigh,.NC 27699-1617
11.Borehole diameter: 4.25 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Geo be DPT above, also submit a copy of this form within 30 days of completion of well
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12.Well construction method: P 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 oneCcopy 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 Quality. Revised Jan.2013
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