GW1-2022-10802_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 I DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for malti-cased wells OR LINER ifa "livable_.
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. I �in.
Company Name "16.'INNER CASING OR TUBING eathermal closed-loon)
WM0701286 EFROMTO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 4 5 ft. 2 in. sch 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.) ft in.
3.Well Use(check well use): NWater Supply Well: TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 4.5 ft• 14.5 ft 2 in. .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 EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. ft
2.5 cement;grout pour
Non-Water Supply Well:
Monitoring ORecovery
265 ft- 3.5 ft- bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19 SAND/GRAVEL:PACK ifa' livable '"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 3.5 ft 14.5 ft- #2 sand prepack/pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if neeess
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soll/mck type,grain sire,etc.'
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 14.5 ft- Silty Sand and Silty Clay
ft. ft.
4.Date Well(s)Competed: 10/17/2022 Well ID=MW-20
ft. ft.
5.Well Location: --ti -
ft: ft.
Dupont-Kentec
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. E
4610 Braxton Road, Grifton ft. ft.
Physical Address,City,and Zip c r t
".21`:1tEMARKS,„ � -
Lenoir -
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ogia ysg JbyfenT opmr
(ifwell field,one lat/long is sufficient) awre Ce Dx O�.ftluwi
vr�ob* ser* w.
a��room�dwwo�om
35.340977 N 77.465896 W Opper ,� 11/11/2021
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 ISA 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 ofthis 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: 2 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: 14.5 (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdierem(example-3@200'and 2@1001) construction to the following:
10.Static water level below top of casing: approx 6 (ft) Division of Water Quality,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
I1.Borehole diameter: 4.25 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
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
• 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 the county health department of the county
where constructed.
Four GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013