GW1--00307_Well Construction - GW1_20240112

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. Opper FR,WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap r licable)
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM _ TO DIAMETER THICKNESS _ MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft• 10 in' sch 40 PVC
List all applicable well construction permits(i.e.Counry,State,Variance,etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER _SLOT SIZE THICKNESS MATERIAL
ID Agricultural OMunicipal/Public 10 ft. 25 ft 2 in. .010 sch40 PVC
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) It. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I8.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft.
Non-Water Supply Well: 3 cement grout pour
21Monitoring ❑Recovery 3 ft. 8 ft• bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
8 ft' 25 ft• #2 sand prepack/pour
o Aquifer Test ❑Stormwater Drainage
ft. ft.
['Experimental Technology ['Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain,size,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 23 ft. Silty Clay
11/7/2023 MW-31 23 ft• 25 ft• Silty Sand
4.Date Well(s)Completed: R. ft.
5.Well Location: ft. ft. ;L"--",..' 's
Scotchman GPM 3010 ft. ft.
JN►V ( ,24
Facility/Owner Name Facility 1D#(if applicable)
ft. ft.
10283 South W.R. Latham Street rlacrn-- :ler,'� �{,��
ft. ft. •, ' '';t �l
Physical Address,City,ard Zip - _ ,.
P 2I,REMARKS
Clarkton t/►f I
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificatio
Digitally signed by Lawrence Opper
(if well field,one lat/long is sufficient)
Lawrence Opp r °"`n-`dWfeoCegServi
34•489280 78.6618437 emRegionalpregionaervices,g.c
canon=wrry1region.imrobing.co n,a=us 11/19/2023
N ��' nab..Mal n ro to not.ovno
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo 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 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 ifnececcary.
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: 25 (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:
10.Static water level below top of casing: approx 15 (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: 4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Auger, DP 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 Sunnly&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 G\V-i North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013