GW1--03443_Well Construction - GW1_20230518

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. O er 14.WATERZONE9;' -
Lawrence FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft
NC Well Contractor Certification Number
15.OUTER CASING"for multi=cased wens.OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. I I, in.
Company Name 16.INNER CASING OR TUBING. eothermal closed-l000l
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 8 ft. 2 i" 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 ❑MunicipaUPublic 8 ft' 23 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
❑Irri ation 0 ft. ft
Non-water Supply Well: 3 cement grout pour
@Monitoring ❑Recovery 3 ft- 6 1 bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
'
LA
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMP CEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 6 ft• 23 ft. #2 sand pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG`attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soit/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft- 23 ft• tan-brn silty Sand
4/3/2023 MW-1 ft. ft.
4.Date Well(s)Completed: ft. ft.
5.Well Location: ft. ft.
Claudette Reges and Becky Smith NC Incident#48776 ft. ft. _
Facility/Owner Name Facility lD#(ifapplicable) -~ l✓^ y}
5304 N. Halifax Road
ft. ft.Physical Address,City,and Zip MAY
21.REMARKS ',
Nash
County Parcel Identification No.(PIN)
r�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificatio
(if well field,one latllong is sufficient) 41 Digita cnaw 2 signed by ante Opper
'�DN: dOLawppero Reglonal
36.0388968 N 77.8515301 W Lawrence Opper eTe�rry�reglonalpmbig.com,c US 4/19/2023
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 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 ElNo 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: 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 oneform. 24.Submittal Instructions:
9.Total well depth below land surface: 23 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if differem(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: approx 9 (ft) Division of Water Quality,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4.0 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Geoprobe- DPT 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 to the 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