GW1--00364_Well Construction - GW1_20240112

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WELL CONSTRUCTION RECORD' •
For Internal Use ONLY:
This form can be used for single or multiple wells 1
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1.Well Contractor Information:
Lawrence D. Opper ^?14.WATER'ZONES gig, .. . :•'
pp FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft.
• NC Well Contractor Certification Number 45:OUTERCASING(for mi ti-casedwe'tls)OR LINER(ifapplicable)
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. : in.
Company Name 'IC:INNER CASING OR TUBING.(geotherinal dosed loop), • :;; s h``"
FROM •TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: _ 0 ft. 14.5 ft. 2 ' is 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
❑Agricultural ❑Municipal/Public 14.5 ft 24.5 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ['Residential Water Supply(single) ft• ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GR01JT' '
FROM _ TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft
3 cement grout pour
Non-Water Supply Well:
3 ft. 14.5 ft. bentonite pour
IZMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation .19.SAND/GRAVEL PACK(if applicable) "`-a''"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
14.5 ft 24.5 • ft #2 sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ['Subsidence Control
c20DR1LLNGLOG(attach additional shetts if no saiy) ., ., r';3a
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/reek type,grain size,etc.)
['Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft• 0.5 ft topsoil or crushed stone
4.Date Well(s)Completed: 11/16/2023 MW-11 0.5 ft24.5 ft. i ' tan-brn sandy Silt
ft 24.5 ft- Partially weathered.rock.;,auger refusal
5.Well Location: ft. ft. • x 4 '+
Vicksboro Grocery& Grill ft. ft. '
Facility/Owner Name Facility ID#(if applicable) JAN 1. 2 2024-
ft. ft.
6215 Vicksboro Road, Henderson
ft. ft.
Iflt iTi ti! n Pr.-.n5:1 9 Lm3r1.
Physical Address,City,and Zip ;,. r
21..REMARKS-t -;..- 1-- , _<, J.V'ec ."+04'. ,, a,
Vance i
County Parcel Identification No.(PIN) , j i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification' PC)
(if well field,one lat/long is sufficient) I Digits• edbyLawrencoOpper
1 DN,cn=tawrena!Opper,o-aegionat
36.305816 N 78.276550 W Lawrence Opp-r�emb aoy@e9 nalprobingsam,r-US 12/11/2023
- - - Dal_.2U22.,2.,2,U.t5 3 erns'
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or DTemporary By signing this form,I hereby certfy that;the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or ONo 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 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: 24.5 (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: (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: 4.5 (in.) 24b.For Injection 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
12.Well construction method: Auger construction to the following: r
(i.e.auger,rotary,cable,direct push,etc.) I
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
136.Disinfection type: Amount: completion of well construction to the,county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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