GW1--05950_Well Construction - GW1_20241009

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14:WAT-ER.ZONES a
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name ft. ft. I
NC3322-A ft. ft.
NC Well Contractor Certification Number ,IS.OUTER CASING(for multi-eased weft OR;LINER(if riplicable)`
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 1 MATERIAL
2.Well Construction Permit#: 0 ft. 15 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): 1T:SCREEN _ ', _. .n,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
El Agricultural ❑Municipal/Public 15 ft. 35 ft• 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1g•GROUT "" 1 `. r " =- _ „,
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft• Cement pour
Non-Water Supply Well:
RIMonitoring ❑Recovery 3 ft. '13 ft• Bentonite pour
Injection Well: ft. ft.
ID Aquifer Recharge ❑Groundwater Remediation ro.19:°SANDJGRAVEL`PACK(if applicable) 7-: •
❑Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑
13 ft• 35 ft• #2 sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft. 11
❑Experimental Technology El Subsidence Control
2(1.DRILLING LOG(attach additional'theets ifneeessary) ; i--
❑Geothermal(Closed Loop) El Tracer FROM _ TO DESCRIPTION(calor,hardness soil/inch type,grain size,etc.)
ID Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 1 ft• Asphalt over paver base
4.Date Well(s)Completed:
8/26/2024 MW-1 D 1 ft• 35 ft• Orange/tan silty Clay over tan-brn silty Sand
ft. ft
5.Well Location:
ft. ft. > t;i•,.. : '..
Reidsville Shell Family Fare#397 • �'k,a "" ' " ' �•
ft. ft.Facility/Owner Name Facility ID#(if applicable) O C T 0 p 2024
ft. ft. I
1025 S. Scales Street, Reidsville ft. ft. ]r, r ,lY
Physical Address,City,and Zip '21:REMARKS , ,., I,r.d+a`,,t,.{:r3'' ,
Rockingham 1
County Parcel Identification No.(PIN)
I
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
36.347064 N 79.665010 W pp
Lawrence O er' 202.9.08 �� � 9/8/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): l Permanent or ❑Temporary By signing this form,I hereby certiji 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 ONo 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: 35 (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: approx 25 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1 '
11.Borehole diameter: 4.5 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Auger construction to the following: f
(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 the1 county health department of the county
where constructed. iI
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013