GW1-2022-08356_Well Construction - GW1_20220502

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells k
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1.Well Contractor Information:
Lawrence D. O 4WitRZU t �i �. ,.E
PPer FROM TO DESCRIPTION '
Well Contractor Name
NC 3322-A ft. ft.
NC Well Contractor Certification NumberTERtiSING.foriniittt cased yells.OR LINER rfa ficable._:.:
FROM TO I DIAMETER 1 THICKNESS 1 MATERIAL
Regional Probing Services ft. ft. in.
Company Name �al'6:INNER CsYiSYl±7G(tt2(rfUB eo'ItierMaiiclosed loo �
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft. 2 i" 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):
Water Supply Well: FROM I TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 5 . ft' 20 ft- 2 '"' .010 sch40 PVC
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18GIf([)T, ' ` _ ,,, .'. �•.•-=`
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0
Non-Water Supply Well: ft 3 ft cement grout pour
Monitoring ElRecovery
3 ft. 4 ft- bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation tws" IGRA
FROM TO MATERIAL' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 ft' 20 ft• #2 sand Prepack/pour
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
RSIT i1+TG:IL ,gtfaiiddthortat sMeetsyt
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilfrock type,grain sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks 0 ft. 1 ft. Concrete over gravel
3/14/2022 MW-2,3 1 ft. 20 ft. Silty/Clayey Sand
4.Date Well(s)Completed: ft. ft.
5,Well Location: ft. ft.
Circle K 2723843 ft rt.
Facility/Owner Name Facility ID#(if applicable)
ft. ft. c_
4470 Hwy 87 South, Sanford
Physical Address,City,and Zip AAAV
Lee
County Parcel Identification No.(PIN) iGh sSr i E�s u
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: :�.
22.Certification:
(if well field,one ladlong is sufficient) LaWren a ''
A°bin95eMces,w
35.424214 N 79.120655 W Opper ;,;& � 4/10/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the icell(s)war(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 0N0 copy ofthis record has been provided to the well owner.
l(thi.c is a repair,fill out known well constriction information and erplain the nature ofthe
repair under 1121 rennarkv section or on the back of 1his.lorm. 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 construction,you can
subunit one(arm. 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
Plor muhiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: approX 12 (ft) Division of Water Quality,Information Processing Unit,
114-ater kwel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 4.25 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Ge0be 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 fonn 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-I North Carolina Department of Environment and Natural Resources—Division of Water Quality' Revised Jan.2013
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