GW1-2022-10762_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This forth can be used for single or multiple wells
1.Well Contractor Information:
14 WATER ZONES
Lawrence D. OPP er �"
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A fL ft-
I
NC Well Contractor Certification Number 15.OUTER CASING 1hr multi,cesedJivells OR LYNER,r1 8" hcablo
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services & fL ; in.
Company Name 16.INNER CA'5ING:ORs.TUBING' e6thertni:closed400 -. ^u
FROM I TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft. 5 fL 2 i" SCh 40 1 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc)
ft. fL in.
3.Well Use(check well use): 17:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft' 15 fL 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft' fL tn.
❑Industrial/Commercial ❑Residential Water Supply(shared) '18:.GROUT FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. ft.
Non-Water Supply Well: 3 cement grout pour
IOMonitoring ❑Recovery 3 ft- 4 ft- bentoniYe pour
Injection Well: ft. fL
❑Aquifer Recharge ❑GroundwaterRemediation 193SAND/GRA�LPACR<, fa' licsllex ? ,, � ,
w4
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft rt
❑Aquifer Test ❑Stormwater Drainage 4 15 #2 sand Prepack/pour
ft. fL
❑Experimental Technology ❑Subsidence Control
20.'DRILLING='1.OG'ittach additional;slitcts if ttcces3 x i'. ,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size etc.
❑Geothermal Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 ft. 15 ft• interbedded silty sand and clay
4.Date Well(s)Completed:
10/28/2022 MW-1 ft. ft.
ft. ft.
5.Well Location: ft. ft.
Robert Brooks ft. ft.
Facility/Owner Name Facility ID#(if applicable) U ,.0 RV E
fL fL
312 Martin Luther King Drive, Elizabethtown it. ft.
Physical Address,City,and Zip 2L REMARKS
Bladen
00 ~
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) ! tally signed by Lawrenceopper
`g D:cn=Lawrence Opper,o=aeglonal
34.626401 N 78.609559 W Lawrence Opper-pbItg5-1ces,ou, 11/17/2022
[e-mail].r-US
Signature of Certified Well Contractor Date
6.Is(arc)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I5A 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 0No copy of this 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#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: 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: 15 (ft.) 24a. For All Wells: Submit this';form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: a PProx 9 ({t,) 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• 3.25 (in.) 24b. For Infection 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
13a.Yield(gpm) Method of test: 24c.For Water Sunoly&Geothermal Wells: In addition to sending the form to
the address(es) above, also submits 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. 6
Forth GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013