GW1--01978_Well Construction - GW1_20240401

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.
NC Well Contractor Certification Number _15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. ' in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) , - -
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft 10 ft 2 ' 1D• 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 .'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural ❑Municipal/Public 10 ft 25 ft' 2 ''} 010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft '"'I
, ,
❑Industrial/Commercial ❑Residential Water Supply(shared) F1R8:OMGROUT M TOMATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft• Grout pour
Non-Water Supply Well: .
oMonitoring ['Recovery
ft' -8 rr. bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL-PACK(if applicable) '- -
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
8 ft• 25 ft• #2 sand/ppk Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary) w
❑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• 25 ft. Silty Clay over silty sand
4.Date Well(s)Completed:
2/27/24 MW-4, MW-5, MW-6 ft. ft.
ft. ft.
5.Well Location: ft. ft.
Selma Perkinson Property Incident No. 5392 ft. ft. '.- #..,-r. 41 4 -'...,1
Facility/Owner Name Facility ID#(if applicable) A P R y
ft. ft. t CU/4
1825 U.S. Hwy 1 North, Wise ft. ft. ill%`„i .:; a _ _, .
Physical Address,City,and Zip 21,REMARKS , ' _ ,_:�r '-r= �5�',
Warren ` ,y",,
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 1
(if well field,one lat/long is sufficient)
Lawrence 1 r,:: ' -.h. mom'„
36.494095 N 78.1731672 W Opper / - MM..wn a 3/15/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): IaPermanent or DTemporary By signing this form,1 hereby certifi,that the well(s)was(were)constructed in accordance
with l5A 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
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: 3 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:
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9.Total well depth below land surface: 25 (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: approxl 5 (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: 5 (in.) 24b.For Iniection 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: construction to the following:
(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&Geothertal 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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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