GW1-2023-00580_Well Construction - GW1_20230109

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
er 14.WATERZONES
Lawrence D. O
PP FROM TO DESCRIPTION
Well Contractor Name ft. ft. f
NC3322-A ft. ft.
NC Well Contractor Certification Number 15,OUTER CASING:for multi-cased welts OR LINER rfa licable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft.. ft. in.
Company Name
16.INNER CASING'ORTUBING eothermalclosed-Imi
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 18 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 18 fL 28 ft- 2 in. 1 .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '18.GROUT
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. ft.
Non-Water Supply Well: 3 cement�grout pour
3 it. 16 ft. bentOnite pour
MMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a Iicalle
FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Storage and Recovery ❑Salinity Barrier
16 fc• 28 1c• #2 sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20::DRILLING LOG,attach additional'sbeets if necessa
❑Geothermal Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUr( p) ock type,grain sire,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 0.5 ft Asphalt over crushed stone
11/18/2022 MWA 0•5 ft' 28 ft, tan-brn sandy Silt
4.Date Well(s)Completed:
ft. 28 ft. Partially weathered rock
5.Well Location: ft. ft.
Vicksboro Grocery& Grill rr ^Y'
ft. ft - ` �...;;�f
l;�C.�'�. �.,�S".a.a
Facility/Owner Name Facility ID#(if applicable)
ft. ft. I n NI Q 9
6215 Vicksboro Road, Henderson ft. ft
Physical Address,City,and Zip 21,`REMARKS`
J
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) oI Ilyslgned by Lawrence Opper
D cn=Lawrence Opper,o=Regional
36.305816 N 78.276550 W Lawrence Opper_pib' 5ervire�oa. 12/12/2022
emaiLlarry@region Iprobirg.c;!,---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 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 ONo 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 hack of this fonn. 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 ofwells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the sane construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 28 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3(200'and 2@100') construction to the following:
10.Static water level below top of casing: approX 21.5 (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: 4.5 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger 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
(gp ) 24c.For Water Supply&Geoth Irma]Wells: In addition to sending the form to
13a.Yield m Method of test: 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. i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water;Quality Revised Jan.2013