GW1--05575_Well Construction - GW1_20230825

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
-I4.WATER ZONES ,u.,,,
Lawrence D. Opper FROM TO .., =DESCRIPTIONI - . . ,w, . ,,;`&-,' ...
Well Contractor Name ft. ft. I
NC3322-A ft. ft.
NC Well Contractor Certification Number
15.:OITCER CASING(for multi-cased Seells):OR LINER(if ap licable). z. '
' FROM TO DIAMETER THICKNESS � MATERIAL
Regional Probing Services ft. ft. in.
Company Name -16.INNER CASING ORTUBING(geothermal'dosed loop)"', • '„
FROM TO _ DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 it 3 ft. 2 ' '°' sch 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.) -
ft. ft. i in.
3.Well Use(check well use): 17.SCREEN,_ .e " ,.„v'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 ft. 18 ft. 2 1°•; .010 sch40 PVC
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. i°•
❑Industrial/Commercial ❑Residential Water Supply(shared) 'FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 1 ft. Cement pour
Non-Water Supply Well:
0Monitoring ❑Recovery 1 ft. 2 ft. ##20Bentonite pour
Injection Well: - - - ft. • ft.
❑Aquifer Recharge 0 Groundwater Remediation - '19.SAND/GRAVEL PACK(if applictble)' r 2 , ` '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 2 ft. 18 it #2 sand. prepack/pour
ft. ft. 1
❑Experimental Technology ❑Subsidence Control
:10.tDRILLING:LOG(attach additional:sheete ifneeeessary) "'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 ft ; grass surface and topsoil
6/12/2023 through 6/14/2023 1 ft. 18 ft. ' Silty Clay over Silty Sand
4.Date Well(s)Completed: ft ft.
5.Well Location:
Former Pembroke Bulk Oil Plant ft. ft �„ ` F�f�"
ft. ft. AUGFacility/Owner Name Facility RN(if applicable) ft ft. AUG 2 202d
S. Jones Street and Blaine Street, Pembroke
ft. kt InfJPFv cfl Pr :atrot ig Link
Physical Address,City,and Zip 2I:41EMARKS�r•;° ,D,SexwPi:.)t - ,,..
Robeson Well ID: MW-5
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ger'
(if well field,one lat/long is sufficient)
34.6800912 r -N 79.19023712 W Lawrence Oppe °° =----- 7/4/2023
�eN, m
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certfy 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 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#21 remarks section or on the back of this forth. 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: 18 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
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10.Static water level below top of casing: 5 (ft.) 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: 3.75 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
Geoprobe DPT
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. 1
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013