GW1-2021-03233_Well Construction - GW1_20210624

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Lawrence D. Opper
FROM TO DESCRIPTION'
WeII Contractor Name ft. ft.
NC3322-A
NC Well Contractor Certification Number 15:-OUTERCASllVC for:mutti cased�tiells OR I INER ifa 'livable.
FROM TO DIAMETER' THICKNESS MATERIAL
Regional Probing Services ft. ft.
Company Name 16r'"INNER'CASING!OR rUBING eatliermal clos"ed loa
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft' 13 ft. 1 !in.,, Sch 40 PVC
List all applicable well construction permits(i.e.('ounty,State,Variance,etc.)
3.Well Use(check well use): I7SGREENi..,
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 13 if 23 ff 1 '"' 010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
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❑Industrial/Commercial ❑Residential Water Supply(shared) 18;GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&A.MOUNT
[Irrigation 0 ft. ft
Non-Water Supply well: 3 cement grout pour
ft
3 ' 12 it• bentonite pour
OMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19:SAND7G"RA�Eh<'PACKIf Iical*le` .� � ....r:.
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 12 fr' 23 it' No 1 sand Prepack,pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
26:DRII�I ING3 O G-attach btldrbouaTlieets tfahecgssa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(cotoq hardness,wil/mck h e,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) 0 if 23 it• silty,clayey sand
4.Date Well(s)Completed: 5/13/2021 MW-6 ft ft.
ft. ft.
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5.Well Location: ft. ft.
Carriage House Cleaners DSCA92-0051
Facility/Owner Name Facility lD#(if applicable)
537 Plaza Circle, Raleigh ft. ft. � fa��,atlon
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Physical Address,City,and Zip
Wake
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient) s _ «c'vo��Lawrence Opper MeoPPa i
6/7/2021�a«iarye1avrooiPoemymzus35.70408 N78.61156 w
Signature of Certified Well Contractor f :; Date
6.Is(are)the well(s): ©Permanent or ❑Temporary
By signing this•form,/hereby certij}'that the-w'ell(sj was(were)construc[ed in accordance
with 15A NCAC 02C.0100 or 15A NC4C 02C.0200 Nrell 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 1/21 remarks section or on the back ol'[his 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: 23 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd Brent(example-3ea100'and 2@100') construction to the following:
10.Static water level below top of casing:
15 approx (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
1 L Borehole diameter: 2.25 (in.) 24b.For Injection Wells: In additi ,to sending the fonn to the address in 24a
direct-push above, also submit a copy of this form within 30 days of completion of well
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12.Well construction method: p construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
..Division of Water Quality,Underg'roundInjection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
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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-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality` Revised Jan.2013
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