GW1--01863_Well Construction - GW1_20240322

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
•
14.WATER ZONES
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft.
15.OUTER CASING(for multi-cased wells)OR LiNER(if ap licable)
NC Well Contractor Certification Number
. FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
WM0501514 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.County,Slate,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 10 ft. 20 ft. 1 in' .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) s.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation ft. ft.
Nun-Water Supply Well:
0 it. 8 ft. bentonite pour
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) `
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
8 ft• 20 ft. #2 sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage ft. ft •
❑Experimental Technology ❑Subsidence Control
(attach
20:DRILLING LOG{ h additionalaheets if necessary) -.
❑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• 20 ft• , Silty Clay over Silty Sand
..4.Date Well(s)Completed: 1/22/2024-- ft. ft.
ft. ft.
5.Well Location: " . ._ft. -'ft. °.^I"'`.71. ..4`.. il c ' •• , -
Speedway,8663.- - . . . ,
'ft:' - - . .ft. �MAR �'
Facility/Owner Name Facility ID#(if applicable) ft. ft. 2 - 1 -
2256 N. Main Street, Tarboro :.,;vrt i - ^ft. ft: v .:: t ,:.Al2.4n ism
Physical Address,City,and Zip . 21',REMARKS `'k�'y'-,*"Fs
Edgecombe TMW-1,TMW-2,TMW-3,TMW-4
County Parcel Identification No.(PiN) Temporary wells-abandoned the same day.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.C tifrcation:
(if well field,one Iat/long is sufficient)
36.0604758 N 79.870038 N, 1/22/2024
Signature of Certifie Contractor Date
6.Is(are)the well(s): ❑Permanent _or I3Temporary By signing this form,i hereby cert0i that the wells)was(were)constructed in accordance
with i5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction Standards and that a
7.Is this a repair to an existing well: ❑Yes or lallo 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: 4 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: 20 (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:.- 1-2 (ft.) - Division of Water Quality,Information Processing Unit,
Ifwaler level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617-._ __ - -
11.Borehole-diimeter: 2`25" (in.) 24b.For-Injection Wells: In addition to sending the form to the address in-24a
Geoprobe above, also submit a copy of this form within 30 days of completion of well i
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 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 ti 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