GW1--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
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