GW1-2021-06787_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
„a
Lawrence D. Opper OMAT�R��ON'L�FROM
FROST TO DESCRIPTION
Well Contractor Name ft. ft.
NC 3322-A
NC Well Contractor Certification Number
15.OUTEICCASING fo"r"maltcased`"wells`OI2LINER ifa"lcabie
FROM TO DIAMETER THICKNESS MATERLAI.
Regional Probing Services rt. rt. in.
Company Name 16.INNER CASINiG QR TUBIYG eoi6erinal'c1o'sed loo
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 r" 5 rt. 2 '"' Sch 40 1 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft. ft. in.
3.Well Use(check well use)• 17.SCREEN ,...
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 20 ft. 2 1°' .010 Sch40 PVC
❑Geothenmal Heatin Coolin Supply) ❑Residential Water Supply ft. ft. in.( P� g PPY) PPY
❑Industrial/Commercial ❑Residential Water Supply(shared) 1 I$'GROUT '�`"' ' F, -7777
FROM TO MATERIAL: EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 3 rt. cement grout pour
Non-Water Supply Well:
❑O Monitoring ❑Recovery 3 e. 4 tt. bentonite pour
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19":-SANH/GRAt LYACK ifa LeabVe �._._
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
4 20 #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
�?ODRILLINGT�(;afy`.attacfialdt6onalsheets if neeessa ,••:r h�„ -: _.. .c.-<;
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock ts•e,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt' 20 rt• Silty Sand
ft. ft.
4.Date Well 6/1/2021 MW-1Rs)Completed: tt. ft.
5.Well Location:
Former Village Convenient Mart
Facility/Owner Name Facility IDA(if applicable) g. ft.
10100 Fayetteville Road, Fuquay Varina
Physical Address,City,and Zip 21:-RENFARKS _ w
Wake
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one ladlong is sufficient) aye/ Ce ,„oN:m=awm co°oa.° s°"•
111�s„gx­h.W
6/20/2021
35.629799 N 78.716634 W Opper " '
�5-
o wii os.ra is:nssioaroa
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 that a
7.is this a repair to an existing well: ❑Yes or END copy ofihis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature gfthe
repair under.H21 remarks section or on the back gl'this form. 23.Site diagram of 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,von can
24.Submittal instructions:
submit one form.
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdr&rent(example-3@200'and 2@100) construction to the follovvmg:
10.Static water level below top of casing:
approx 10 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4.5 (in.) 24b.For Infection Wells: In addition to sending the fonn to the address in 24a
Auger above, also submit a copy of this form within 30 days of completion of well
12.Well construction method gr 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
i
13a.Yield(gym) Method of test 24c.For Water Snowy&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 G W-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013