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HomeMy WebLinkAboutGW1--00342_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: , '.14.WATER ZONES',/ .. . z Lawrence D. Opper FROM TO DESCRIPTION Well Contractor Name ft. ft. NC3322-A ft. ft. I , NC Well Contractor Certification Number =15.OUTER"CASING(for multi-cased"wells)'OR'LINER(if ap`licable)_'n FROM TO DIAMETER THICKNESS MATERIAL Regional Probing Services ft. ft. in. , Company Name .16.:INNER CASING OR TUBING(gedth'ermal closed-loop),.' • ,, ' FROM TO DIAMETER THICKNESS MATERIAL 2.Well Construction Permit#: 0 ft. 3 ft. 2 it' 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 ,_ .. .. .;,a., _ , Water Supply Well: FROM TO DIAMETER . SLOT SIZE THICKNESS MATERIAL ❑Agricultural ❑Municipal/Public 3 ft 13 ft. 2 i°' 010 sch40 PVC ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. �n • ❑Industrial/Commercial ❑Residential Water Supply(shared) 18'GROUT` ' '''� FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ❑Irrigation 0 - ft• 1 ft cement grout pour Non-Water Supply Well: lMonitoring ['Recovery1 fr. 2 ft bentonite pour Injection Well: ft. - ft. ❑Aquifer Recharge ['Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)..;` ,wA",/. '"". FROM TO MATERIAL . . EMPLACEMENT METHOD ['Aquifer Storage and Recovery ['Salinity Barrier ft. ft. 2 13 #2isand prepack/pour ❑Aquifer Test ❑Stormwater Drainage - ft. ft ❑Experimental Technology ['Subsidence Control '20.DRILLING LOG;(attach'additional.sheets itnecessary)'; ; ry.` ❑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. 13 ft i Silty Sand over Silty Clay 11/9/2023 MW-1 ft. ft. 4.Date Well(s)Completed: ft. ft. !.y_ _A 5.Well Location: ft. ft. '„'."^%, il.�d r.. @•r' A.-:,,Li Speedway 7941 ft. ft. JAN 1 , Facility/Owner Name Facility ID#(if applicable) �r�74 ft. ft. 3462 Richlands Road, Jacksonville ft ft nl;�rr,:r;.,iz-,I P:,=„,os ;;j t tSCI D Oi0tti-2 Physical Address,City,and Zip a4 ,- _ �'21:REMARKS„„ii ��,,,...,. .,,. ., Onslow County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificatio \" (if well field,one lat/long is sufficient) f a99unra9�eaey� eo�ooa, 34.76312240 N 77.4865028 W Lawrence Opper C� .°�', ng om�""Ce; 11/21/2023 D, 20]3.1,iI 1,u39-09'00' Signature of Certified Well Contractor i 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 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 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 I repair under#2/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 one form. 24.Submittal Instructions: 9.Total well depth below land surface: 13 (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: 1 10.Static water level below top of casing: 3 (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: gr, 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. i Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 1