GW1-2022-09953_Well Construction - GW1_20221031

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. O 14-WATER ZOXES'�,',
pper FROM TO DESCRIPTION
Well Contractor Name ft.
NC3322-A ft. f,
NC Well Contractor Certification Number 15.OUTER CASING for in I ulti-','-' R T=L
FROM T( DIAMETER MATERIAL
Regional Probing Services f,. I ft
I i in. I I
Company Name 16.INNER CASINGkOR TURING'fie6ithernud closed loo
FROM I TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit N: 0 1" 15 ft- 2 sch 40 1 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft. f, in.
3.Well Use(check well use): -SC P,
Al.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
oAgricultural OMunicipal/Public 5 It 20 ft. 2 "' 1 .010 SCh40 PVC
OGeothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft. in.
01ndustriall/Cornmercial OResidentiall Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Oirrigation ft. ft.
Non-Water Supply Well: 0 3 cement grout pour
MMonitoring ORecovery 3 ft- 4 ft bentonite pour
Injection Well: ft. ft.
OAquifer Recharge OGroundwater Remediation
OAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
C Aquifer Test OStormwater Drainage 4 l" 20 ft. #2 sand pour
ft. ft.
ClExperimental Technology OSubsidence Control 0.]DRILLINGLOGt attach,gilditio Vsh 4fziec na
0 3
F
F
FROM
M
_'SAND
FROM f f t t
41
ft_
10_DJULU
OGeothennal(Closed Loop) ElTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size etc.)
ft
OGeothermal(Heating/Cooling Return) 00ther(explain under 421 Remarks) 0 ft. 15 ft• tan-bm silty Clay
I ft. ft.
9/7/2022 MW-1,MW-2, MW-3 15 f- 20 Tan Silty Sand
4.Date Well(s)Completed: f
ft ft.
ft. E
5.Well Location: ft. ft 077
Perdue AgriBusiness
ft. ft
Facility/Owner Name Facility ID4(ifapplicable) ft. ft OCT 3 1
242 Perdue Road, Cofield, NC 27922 ft. ft.
Physical Address,City,and Zip
�.21.REMARKS,,�"
Edgecombe
County Parcel Identification No.(PIN)
IL
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one latAong is sufficient) signed by Lawrence Opper
W;cn-LawreAce Opper,�Reglwal
36.364011 76.8971628 Lawrence Oppe Probing Servlce�ou.
N W 10/3/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary 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: OYes or ONo copy of this record has been provided to the well owner.
ffthis is a repair,fill out known well construction information and explain the nature of the
repair under#21 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: 3 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 oneform. 24.Submittal Instructions:
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this ib. within 30 days of completion of well
For multiple wells list all depths iidifferent(example-3@200'and 2@100') construction to the following:
J
10.Static water level below top of easing: approx 15 (ft.) Division of Water Quality,I Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Clt er,Raleigh,NC 27699-1617
11.Borehole diameter: 3.25 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Geoprobe construction to the following:
(i.e.auger,rotary,cable,direct push,etc-) I
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ccinter,Raleigh,NC 27699-1636
i
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[one copy of this form Within 30 days of
13b.Disinfection type: Amount: completion of well construction to jthe 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