GW1--03476_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
Lawrence D. Opper 14.WATER ZONES
FROM _ TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if appllicable)
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. 2 fI 2 i"• 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
❑Agricultural ❑Municipal/Public 2 ft. 12 ft• 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑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:
RIMonitoring ❑Recovery 1 R. 1.5 ft. bentonite pour
Injection Well: ft. ft.
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATF:RIA1. EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier -
1.5 ft' 12 ft. #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage ft. • ft. -
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sloe,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 12 rt. Silty Sand over hard Sandy Clay
4/13/2024 MW-5 ft. ft.
4.Date Well(s)Completed: "'fr. ft. -%\C L Ii 1/E -
S.-Well Location:
ft. ft.
Mt. Airy Superette (Former) ft. ft. JUN 1 1 2024
Facility/Owner Name Facility ID#(if applicable)
ft. ft. lrAo'w l i.,•6627 NC Hwy 72, Pembroke ft ft 4Y,.,
Physical Address,City,and Zip
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21.REMARKS _
Robeson
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ' a�
(if well field,one lat/long is sufficient) -igitallysigne›eyLawrenceoppe,
Lawrence O DN cm-Lawrence Oppeto-Regional
34.683562 N 79.136785 W, Pp"r ema'[e-mail],c=US 5/1/2024
D..2021,02.11 1534.49 05190
Signature of Certified Well Contractor Date
6.is(are)the well(s): IZPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with i SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IZ1No 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: 12 (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@I00') construction to the following:
10.Static water level below top of casing: approx 4 (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
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.)
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 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