GW1--00365_Well Construction - GW1_20240112

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WELL CONSTRUCTION RECORD For Internal Use ONLY: i
This form can be used for single or multiple wells
1.Well Contractor Information: 1
14.°WATER ZONES
Lawrence D. Opper FROM TO . DESCRIPTION DESCRIPTION '
Well Contractor Name ft. ft. I '
NC3322-A ft. ft.
NC Well Contractor Certification Number -15:OUTERCASIN i'(far multi-cased wells)OR LINER(if ap l "tcable) ;„ .• '"
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. :in.
Company Name `I6.INNER CASING OR TUBING((eothermat dosed loop),".;'., . ,,• `.
FROM TO DIAMETER • THICKNESS MATERIAL
2.Well Construction Permit#: • 0 ft* 17.5 ft. 2 ,tn• sch 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.) -
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 17.5 ft. 27.5 ft 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
t8 GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
12 Irrigation 0 ft. ft
Non-Water Supply Well: 3 cement grout pour
❑Monitoring ❑Recovery 3 ft. 15.5 ft bentonite pour
Injection Well: ft. ft. -
❑Aquifer Recharge ❑Groundwater Remediation - 19 SAND/GRAV.ELL PACK(iffapplicable) Y u. _,„',
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
15.5 ft. 27.5 ft. #2 sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control '
s 20:.DRILLING'LOG.(attach addiiionalsl eets'if necessary) ..�,,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. 0.5 ft. ; • crushed stone
4.Date Well(s)Completed: 11/16/2023 MW-8 0.5 ft. 27 ft- tan-brn sandy Silt
ft- 27.5 ft. Partially weathered rock
5.Well Location: ft. ft. .`
Vicksboro Grocery& Grill ft. ft �' 'ASP' ; '" -
Facility/Owner Name Facility ID#(if applicable) JAN i 4 ZUZ4
ft. ft.
6215 Vicksboro Road, Henderson It. ft.
Physical Address,City,and Zip '2L REMARKS.. ,•yea` , w tut l if D�jh r z�a,•' 1 1�
Vance �
County Parcel Identification No.(PIN) i
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:I I
(if well field,one lat/long is sufficient)
Digitaltyslgne LawrenceOpper
'Y DtQ cn=lawren�e Opper.�Reglowl
36.305816 N 78.276550 W Lawrence Opper1 maiikary@regtonalpobingmm,c=5S 12/11/2023
Dal...2022.12.1210.4533 05'00'
Signature of Certified Welt Contractor i Date
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6.Is(are)the well(s): IZZPermanent or ❑Temporary By signing this form,I hereby cert(fy that:the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No 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#11 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: 27.5 (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: i
10.Static water level below top of casing approx 23 (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 Infection Wells: In addition to sending the form to the address in 24a
AU er above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g construction to the following: l
(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 i the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 .
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