GW1-2021-04370_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: O�` i
Lawrence D. Opper TO WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name Q e5S ,J ft. R.
NC3322-A o� ft. fr.
NC Well Contractor Certification Number 15.OUTER CASING flit moth cased wells'OR LTNER if'a 'bcable
\Cf�f�t� Q� FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services fr. f, in.
Company Name 16,INNER CASING'OR TUBING eothermal eldsed-loo -
w WM0401252 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 15 ft' 1 'i"• Sch 40 PVC
List all applicable well construction pennus(i.e.C'ount),Stale,Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 "' 30 ft' 1 tO' .010 SCh40 I PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.,GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&A.MOUNT
[Irrigation 0 f. 3 ft• cement grout pour
Non-Water Supply Well:
3 f` 13 f` bentonite pour
@Monitoring ❑Recovery
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation FROMAND/GRAVE MATERIAL Eatrtnc
"SACK`(if lisbfe s ..-
TO EMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fr. ft.
❑Aquifer Test ❑Stormwater Drainage 13 35 #2 sand Prepack/pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
°"20;-DRILI,ING.tit�G attachaddibonah?§beets-tf--necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 30 ft• tan-bm silty Sand
4.Date Well(s)Completed: 1/19/2021 MW-16 ft• 30 f`• Partially-Weathered Rock
ft. ft.
5.Well Location: ft. ft.
Tank&Tummy#1
Facility/Owner Name Facility to#(ifapplicable) ft. ft.
3867 US Hwy 311 Randleman
Physical Address,City,and Zip 21.REMARKS
Randolph
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field one[at/long is sufficient) Dlgi 11"1gn dby Wwrence Opper
.i4==1ence Opper. kgional
35.802036 N 79.823937 W Lawrence Opper f4obingS @regioo�, 2/10/2021
-em5a=larty�r gi Iprobing.mm,c=US
PE 2B21fl?161i/ir29 a"a9'
Signature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.DI00 or 15A NCAC,02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of dtis 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: 1 construction details. You may also attach additional pages if necessary.
For multiple iniection or non-water supply wells ONLY with the same construction,you can
submit one%rm. 24.Submittal Instructions:
9.Total well depth below land surface: 30 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far muhiple wells list all depths ifdifferent(example-3(d@200'and 2@100) construction to the following:
10.Static water level below top of casing: approx 20 (ft) Division of Water Quality,Information Processing Unit,
If water 1cvel is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 3 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Auger-DP above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g 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 SunDly&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 jthe county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources--Division of Water Quality Revised Jan.2013