GW1-2022-10798_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name ft. ft,
NC3322-A ft. ft,
NC Well Contractor Certification Number 15.OUTER CASING,for multi-cased wells ?!TI ER if a"licable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft ft I in.
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 5 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 5 ft 20 ft. 2 i°' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL FAIPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 3 ft. cement grout pour
Non-Water Supply Well:
3 fr. 4 ft bentonite pour
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19."SAND/GRAVEL PACK if a li6hle
FROM TO MATERIAL EMPLACEMENTMETHOD .,
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 ft. 20 ft. 1 #2 sand I Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. I ft.
❑Experimental Technology ❑Subsidence Control .
20:DRILLING LOG attach additional-sheets if necessa
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIFFION color,hardness soil/rock type,grain s've,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 20 ft. Orange silty Clay over tan-brn silty Sand
9/26/2022 MW-5,MW-6,MW-7 ft. ft.
4.Date Well(s)Completed:
ft. ft.
5.Well Location: ft. ft. l"" 'I---' 1 " V
h
Earl's Service Center ft. ft. 2022
Facility/Owner Name Facility ID#(if applicable) _
ft. ft.
3964 Raleigh Road, Henderson ft. ft. In;L,;;,, �, r n,.-,� tjn,%
,Physical Address City, - -y ty,and Zip 21,REMARKS': Al
Vance
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) Digitally signed by Lawrence Opper
}DN:c-Lawrence Opper,o=Regional
36.277150 N 78.406339 W Lawrence OppersP°hing5ervlces,oua 10/16/2022
eiriaiklarry@reglan IDroblrgtom,r-US
Signature of Certified Well Contractor 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.
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
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 wish the same construction,you can
submit 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 ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing approX 12 (ft) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4.25 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Geoprobe Direct-Push 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 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 t tie 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
' I I