GW1-2021-01654_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 FR WATER ZONES:',
FROM TO DESCRIPTION
Well Contractor Name 11 ft. ft
Q�R Vn rt. rt.
NC3322-A 'SStn9
11?to 15.OUTER CASING for moth casedw1lls OR LIVER if a''licable
NC Well Contractor Certification Number tt° n
1�1°tt�►pwR 5910 FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. I ft.
Company Name 16.INNER CASING OR TUBLNG fizeirithermal closed-loop)
FROM I TO DIAMETERI THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 13 ft. 2 iin. Soh 40 PVC
List all applicable well construction permits(i.e.County.Slate,Parlance,etc.) ft. ft. j in. '
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 ft. 13 f` 2 '"' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO < MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 1.5 ft• cement grout pour
Non-Water Supply Well:
@Monitoring ❑Recovery 1.5 ft• 2 f`• bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a tics'61
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
2 f`• 13 f`• #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control --L
20.DRMLINGLOG attach'additiorial sheets if neeessa. '
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soft/rock xtype,emin sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 13 ft. Light brown silty sand
ft. ft.
4.Date Well(s)Completed: 1/14/2020 MW-14R,MW-16R
it. ft.
5.Well Location: ft. it.
Former Classic Toyota
Facility/Owner Name Facility ID#(if applicable)
ft. it.
4513 Chapel Hill Blvd., Durham, NC
Physical Address,City,and Zip 21.REMARKS ,
Durham
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification
(ifwell field,one ladlong is sufficient) Dyaaib signed by Lance upper
N:-L-ente Opper,o=Regiomi
35.9610683 N 78.973935 W Lawrence Opper Yro6ingS­1CPS�� 2/10/2021
.earsnaar< ice1,.., ota�gmmc=us
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that W.e wells)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 FlNo copy q)':his record has been provided to the well owner.
if thus it a repair,fill out known well construction information and erplain the nature o f the
repair under 421 remarks section or on the back g1'this.1orm. 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 ifnecessary.
For multiple injection or non-water supply wells ON/Y with the same construction,van can
submit one fame 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
For multiple wells list all depths ifdiftrent(example-3Ca,200'and 2<u,1001 construction to the following:
10.Static water level below top of casing: approX 6 (ft) Division of Water Quality,Information Processing Unit,
Ifwater lerel is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 4 (in.) 24b.For Infection 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.) I
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. I
Form GW-1 North Carolina Department of Environment and Natural Resources-Disision of Water Qu I alit Revised Jan.2013