GW1-2022-08383_Well Construction - GW1_20220502

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I
1.Well Contractor Information:
Lawrence D. Opper FROM TO I DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A
NC Well Connector Certification Number
s�15 OUTER'CAS1N l for'i" lu tt-ca wells;OR &INER tcatile s"
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name ;X'6 ININER,CSASING OR TUBINia 6iWrmal cliisetl loo ;
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft. 2 i" Soh 40 PVC
List all applicable well construction pennits(i.e.C'ounty,.S'tate,Variance,etc.) ft. ft. in.
3.Well Use(cheek well use):
Water Supply Well: FROM TO DIAMETER SLOTSIZE_ THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 r`• 20 r`' 2 i" .010 1 Sch40 I PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) t8.�;ROUT 0,;,,i;'
FROM TO MATERIAL EMPLACEMENT:METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft• cement grout pour
Non-Water Supply Well:
IvJMonitoring ❑Recovery 3 r`' 4 ft- bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation +19.2SAID1GRtA� PAKifa tii�bYe
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 4 ft• 20 r`' #2sand Prepack/pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
2Q.�DR11LING .rOG,attaclCaadaitional,shouts,ifnieessary f...,.:'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,wil/rock type, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 rt 20 ft Light brown silty sand over Clay
4.Date Well(s)Completed:
3/15/2022 MW-1ont
ft. ft.
5.Well Location: ft. ft. 4:
Arnold's Corner
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
407 NC Hwy 15/501
�P
Physical Address,City,and Zip -
;21:=REMARKS 3�• ` 'i:= x ';r �.Moore ""` Uri
IR
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one fat/long is sufficient) frafj signed by le-Opper
i .r+r=lavaen[e Opper,a=Reglonal
35.3777071 N 79.28898 W Lawrence Opper,�rpbing,rv1CeSOU 4/13/2022
^em511_1arry@reg1ona1prob1ng mm,c=US
Signature of Certified Wel("Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC.02C.0200(Yell 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 owner.
IJ7hi.c is a repair,fill out known well construction information and erplain the nature of the
repair under 1121 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 construction,you can
suhmit 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 if dijerent(example-3@200'and 2@ya 100) construction to the following:
10.Static water level below top of casing: approX 6 (ft) Division of Water Quality,Information Processing Unit,
!f water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Geoprobe above, also subunit a copy of this form within 30 days of completion of well
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 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