GW1-2022-08974_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. O er i 14.WATER ZONES,.',.
pp FROM TO DESCRIPTION
Well Contractor Name ft. ft. I
NC3322-A f` f` f
NC Well Contractor Certification Number -15.:OUTEWCASING for'multi=cased:Wells)Mal if a`licable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name 16.'INNER CASING OR TUBING eother'mal closed-loo
WM0501497 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 20 ft. 1 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 20 ft 35 ft. 1 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(sin(single) f. ft.
❑IndusV IS.-GROUT,ial/Commercial ❑Residential Water Supply(shared) FROM TO* MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft.
Non-Water Supply Well: 5 cement grout pour
5 fr. 18 ft- bentonite pour
13Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation A9.SAND/GRAVEN PACK(if a licahle)
FROM TO MATERIAL r EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
18 f`• 35 f`• #2 sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.`DRILLING I.O;G,attach'addi6iiihsheets•if neerssa
❑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 f`• 25 ft- Silty Sand
7/21/2022 MW-24 25 f`• 35 f`• weathered rock/saphrolite
4.Date Well(s)Completed: ft` 35 f`• bedrock refusal
5.Well Location: ft. ft.
Former Diazit Company . .r,
f[. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft S F P 1 9 2022
941 US Hwy 1, Youngsville ft. ft.
Physical Address,City,and Zip
21:REMARKS
Franklin
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: o'�a0yvd�se0pcer
(if well field,one lat/fong is sufficient) Law ence S orv:a eMeo ao x 9m�i
36.028669 78.505671 O er P�S�9�MCexa.
r ra°�V^Y�rPa:alFmbin9ccm, 8/9/2022
N w pp Date 7072DeD91551 9 0a'00
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the wells)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 gjthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 921 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
S.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
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 35 (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: (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2.5 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Geoprobe DPT 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
13a.Yield(gpm) Method of test: 24c.For Water Sminiv&Geothermal Wells: In addition to sending the form 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 Ithe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013