GW1--04005_Well Construction - GW1_20240708

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 IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
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. 4 ft. 2 in- 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 I THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public 4 ft. 9 ft. 2 in. - .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply ft• ft• in.
( g/ g PP Y) PP Y
-
❑Industrial/Commercial ❑Residential Water Supply(shared) 1g.GROt T
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 7 ft. Cement pour
Non-Water Supply Well: --
lMonitoring ❑Recovery 2 f`. 3 ft• 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 3 ft. 9 ft. #2 sand prepack/pour
❑Aquifer Test ❑StonMwater Drainage - . -
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additionsd sheets 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. 9 ft. Orange/tan-bm silty Sand
5/21/2024 MW-17 ft.
9 ft. Rock refusal
4.Date Well(s)Completed: ft. ft.
5.Well Location: ft. ft.
Sundrop Bottling Company ft. ' ft. `" t- r ; ' U
Facility/Owner Name Facility ID#(if applicable) ft.
-
2406 W. Raleigh Blvd., Rocky Mount ft. ft. -
Physical Address,City,and Zip
21.REMARKS
Nash
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.C 'fication:
(if well field,one lat/long is sufficient)
35.9188191 N 77'826541 6/3/2024
tgna ofCe a ell Contractor Date
6.Is(are)the well(s): ZPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A 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 IllNo 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
S.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: 9 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: approx 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: 4'S (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Auger 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 Suooly&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-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013