GW1-2021-04556_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:
14:2A'1cATER ZONES
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name
NC 3322-A ft. tit.
NC Well Contractor Certification Number
M,'DUTEWCASING'for.multi casedfve115'OR�LTNER.ifa"licahle .y
FROM - TO DIAMETER THICKNESS MATERL4L
Regional Probing Services ft. ft. in.
Company Name ;16.1NNER CASING OR TUBING. eotherm`sl,etosed-loo r „
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rt. 15 rt. 1 1° Sch 40 PVC
List all applicable trell construction permits(i.e.County,5•tate,Variance,etc.)
in.
3.Well Use(check well use): 17.SCREEN2.
� .„
Water Supply Well: FROM TO DIAMETER I SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 15 ft' 125 rt' 1 '"' .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
❑Irrigation 0 r" 3 ft• cement grout pour
Non-Water Supply Well: 3 ft- 13 ft- bentonite'' pour
❑O Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation !,,,',19.1°SAND/GRAVEL,-,PACK-(ifa0plicAbig '..
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
13 ft• 25 ft• #2 sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. rt.
❑Experimental Technology ❑Subsidence Control
j 20'°DR2L'ING'Lt�G'i attach.addii,o�al�heets if rieeeSsa . ;.<.,.'�.>_
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soillrock type rain sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 25 ft. Silty Clay over Silty Sand
ft rt. .
2/22/2021 MW-1
4.Date Well(s)Completed: it. ft.
5.Well Location:
Grocery Boy 39
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 9
3000 Kildaire Farm Road, Cary ft. ft. Ut1it
Physical Address,City,and Zip
u�
Wake pW `w
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: Dgrta1ry ^"a0pa'
(ifwell field,one lat/long is sufficient) Lawr `'°ro""='�"'nieOOP•`•o-"�1pnd1
,'P blip SeMca oµ
35.7162416 N 78.78834 W Opper " '" '°�'"°��`°" 2/24/2021
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W M11.0]34 t&,3.d3 d5V0'
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the uell(s)was(were)constructed in accordance
with 15A NCAC 01C.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 gfthis record has been provided to the hell owner.
If this is a repair,fill out known well construction information and explain the nature o(the
repair under 421 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,your can
submit one forms. 24.Submittal Instructions:
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(exatnple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 18.8 00 Division or Water Quality;Information Processing Unit,
If water kn el is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.Borehole diameter: 2.5 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Geoprobe DPT 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 Suaoly&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-Division of Water Quality Revised Jan.2013