GW1-2021-01653_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY: n p D
This form can be used for single or multiple wells
1.Well Contractor information: I Untt
14.WATER ZONES" toil
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name ft. I ft.
NC3322-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING'for multi-cased willi OR LINER if a`licable
FROM TO DIAMETER, THICKNESS MATERIAL
Regional Probing Services rt. ft. ;in.
i
Company Name 16.INNER CASING:OR[U$LNG eothefinal eloied-lot "
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 3 ft. 1 in• sch 40 PVC
List all applicable urll construction pennies(i.e.C'ounty.5•mte,Variance,etc.) ft. ft. in.
3.Well Use(check well use): 15.SCREEN '� :`• ..
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 3 ft' 13 ft. 1 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) `Y8:GROUT
FROM TO MATERIAL EMPLACEMENT:METHOD&A-MOUNT
❑lrri ation 0 ft. 1.5 ft. cement grout pour
Non-Water Supply Well:
❑+Monitoring ❑Recovery 1.5 tt 2 ft bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 119.E AND/GRA�L PACK(if.a Ucobii'
MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft ft
❑Aquifer Test ❑Stormwater Drainage 2 13 #2 sand Prepack/pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
2Q.DRILLING LOG attach additional sheets if necessa " - +
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/mck t3lie,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 I'L 13 ft Light brown silty sand
e. rt.
4.Date Well(s)Completed:
1/21/2020 MW-7R
ft. ft.
5.Well Location:
Former Classic Toyota
Facility/Owner Name Facility IDA(ifapplicable) ft. ft.
4513 Chapel Hill Blvd., Durham, NC
Physical Address,City,and Zips
,21.REMARKS
Durham
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: '
(if well field,one ladlong is sufficient)
Italy signed by Lawrence
' Oper r
:nlrteneOpper,�aegl I
35.961581 N78.974713 WLawrence Opper-Probingsewices,ou, =Us
2/10/2021m =L c
Signature of Certified Well Contractor Date
6.is(are)the well(s): Permanent 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 thot_a
7.Is this a repair to an existing well: ❑Yes or END copy ofthis record has been provided to the well owner.
If this is a repair,fill out known ttell construction information and explain the nature of the
repair under fell remarks.section or on the back of this farm. 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 farm. 24.Submittal Instructions:
9.Total well depth below land surface: 13 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/br multiple wells list all depths ifdifjerent(example-3@200'and 2C100) construction to the following:
10.Static water level below top of casing:
approx 6 Division of Water Quality,Information Processing Unit,
(ft.)
/f tyaler level is above casing.use"+• 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter.- 3 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Geoprobe 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 Suaah•&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 G W-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013