GW1-2021-03541_Well Construction - GW1_20210607

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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. j
NC 3322-A
NC Well Contractor Certification Number 15..OUTER CASING for.miilticased wells`OR LINER if a 'licabN
FROM TO DIAMETER' THICKNESS MATERIAL
Regional Probing Services ". rt• in.
Company Name 16.INNER CASING OR T13>iLNG- eothe'rmal elosed400
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 et' 8 ft. 1 i" Soh 40 PVC
List all applicable strR construction permits(i.e.County,State,Variance,etc.)
ft. f[. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8 rf 18 rf 1 "' 1 1 .010 SCh40 PVC
❑Geothenmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT"
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 3 ft• cement grout pour
Non-Water Supply Well:
[2]Monitoring ❑Recovery 3 rt' 7 rt' bentonite pour
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELiPACK.it-a
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
It' 18 ft. #2 sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. tt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach-addi66hal',Vkets ifm'6cessa,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin sim,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 rL 15 ft. Silty/Clayey Sand
4.Date Well(s)completed: 4/30/2021 MWA 15 rt• 18 rt• weathered rock/Saphrolite
ft. ft.
5.Well Location:
Minnie L. Moore Property ft. ft.
Facility/Owner Name Facility lD#(if applicable)
ft. ft.
703 Rock Quarry Road, Raleigh tt ft u
Physical Address,City,and Zip
21:REMARKS` ) r
Wake ..l
-pVJR Sec€l
County Parcel Identification No.(PIN)
IX T
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certificatio 0g Wy�^�"a eAttOp�`
(ifwell field,one lat/long is sufficient) 4awrLinced �°p0
35.770911 N 78.620102 W Opper "'°"n 5/26/2021
Date 102I.p6411,31 J6 L6110
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify thai the well(s)it-as(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 gfthis record has been provided to the shell owner.
lfthis is a repair,fill out known well construction information and explain the nature ofthe
repair under 1121 remarks section or on the back of thisJorm. 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 sane construction,yns can
submit one farm. 24.Submittal Instructions:
9.Total well depth below land surface: 18 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 1@100) construction to the followng:
10.Static water level below top of casing:
approx 15 Division of Water Quality,Information Processing Unit,
(ft.)
1/water level is above casing.use•'+'• 1617 Mail Service Cc I niter,Raleigh,NC 27699-1617
11.Borehole diameter: 2.5 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Geoprobe-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.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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