GW1-2022-08954_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. Ot�t�er 14.WATERZONESs."
pp FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. f,
NC Well Contractor Certification Number A S;OUTER'CASING;(for mull-cased wells)OR LINER ifa cable ,
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. I in.
Company Name 16.�INNER CASING=ORTUBING eothernmai'-dosed-looFROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 It' 2 ft. 2 in. sch 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 17.'SCREEN-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft. 12 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
8.GROU
❑ t T'
Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL" EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. ft.
Non-Water Supply Well: 1 cement grout pour
1 ft. 1.5 ft• bentonite pour
(AMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVELPACK if a li6ble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
1.5 ft• 12 ft. #2 sand Prepack/pour
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
❑Experimental Technology []Subsidence Control
40.DRILLING LOG tattach additional=sbeets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 12 ft• tan silty Sand
7/19/2022 ft. ft.
4.Date Well(s)Completed: ft. ft. 1-4
YZ. ���� At E1- �
5.Well Location: ft. ft. _
Circle K 2723165 ft. ft. S E. 11LL
Facility/Owner Name Facility ID#(if applicable)
1313 W. Ehringhaus St. Elizabeth City ft. ft. Inror Pry. W�.,.�t'J un l
ft. ft. v `
Physical Address,City,and Zip ;,,
21:REMARKS"",
Pasquotank Replacement Monitoring Wells
County Parcel Identification No.(PIN) MW-3R,MW-6R, MW-7R, MW-1OR
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/hong is sufficient) Digitallys gned by Law ence upper
C DN:cn=lawrence Opper,a=Regional
36.29428 N 76.23999 W Lawrence Opper_embin9,----. Q(�
aibWrry�nylonalplbing.I-.c-US 8/9/2022
Signature of Certified WellrContractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify 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 E]No copy of this record has been provided to the well owner.
1f this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 4 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
submit are 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
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: approx 4 (ft) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 4.25 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a.
Geoprobe above, also submit 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
1
13a.Yield(gpm) Method of test 24c.For Water Supply&Geothermal Wells: In addition to sending the forth 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 Ian.2013