GW1-2021-01490_Well Construction - GW1_20210429

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 ZON+ES
FROM TO DESCRIPTION
Well Contractor Name
NC3322-A
NC Well Contractor Certification Number %15.OUTER CASING foryital'ti cased"wells'OR Lil\ER if a""
"'livable
FROM TO DIAMETER! THICKNESS1 MATERIAL
Regional Probing Services e. ft.
Company Name '46.INNER CASING OR TUBLNG(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 2 rt. 2 'in' sch 40 PVC
List all applicable well construction permits(i.e.County,Slate,Variance,etc.) in.
3.Well Use(check well use): «1'7.SCREEN
Water Supply Well: FROM TO DIAMETER .SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 ft. 12 ft 2 in. .010 sch40 PVC
❑Geothenmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. I in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
RFRTO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑trri ation 1 . cement grout pour
Non-Water Supply Well:
(]Monitoring ❑Recovery 1.5 ft• bentonite pour
Injection Well:❑Aquifer Recharge ❑Groundwater Remediation RAVEL PACK(if a licabl`)TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier❑Aquifer Test ❑Stormwater Drainage 12 f` #2 sand prepack/pour
❑Experimental Technology ❑Subsidence ControlNG LOG attach additionaL`theets if.n"ecessa"❑Geothermal(Closed Loop) ❑Tracer TO DESCRIPTION(color,hardness,miRtrock h e rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f`' 12 ft. !Silty Clay over Silty Sand
1/4/2021 Well ID=MW-1,MW-2 tr. ft.
4.Date Well(s)Completed: ft rt
5.Well Location: ft. fICTI
t.
Stedman Auto Service ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
7213 Clinton Road, Stedman
ft ft. sln Unit
Physical Address,City,and Zip r
21r REMARKS_.
Cumberland
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certificatio
(ifwellfield,onelat/longissufficient) �_aW ence D"""=� ne00°"°'""""
;s,rAm"q se�zn.w.
36.320482 N w ppper 79.628936 Ot• 05 '"�" "m � 1/27/2021
Dots 20}I.DI l)16.11:16-0StlO
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or []Temporary By signing this form,I hereby certify that the xrl/(s)was(were)constructed in accordance
with 15A NCAC OTC.0100 or 15A NCAC 02C.0200 IVel/Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or E]No copy ofrhis record has been provided to the well owner.
ifihis•is a repair,fill out known well construction information and explain the nature ofilte
repair under 921 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: 2 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,vau can
submit one form. 24.Submittal instructions:
9.Total well depth below land surface: 12 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrJjerent(example-3Q200'and 2C100') construction to the following:
rox
10.Static water level below top of casing: a pp 3 (ft.) Division of Water Quality,Information Processing Unit,
!f water le-we/is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 4.25 (in.) 24b.For Infection Wells: in addition to sending the form to the address in 24a
Auger-HSR 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 SuDDIv&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit and 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. I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Qua litv Revised Jan.2013