GW1-2021-02037_Well Construction - GW1_20210624

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Lawrence D. Opper 14.WATER ZONEi r;
FROM TO DESCRIPTION,
Well Contractor Name
NC3322-A
NC Well Contractor Certification Number AS,OUTER CASING for muiti=caL _V_'�rJls OR:IaIIYER if a` litable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services rt. rc. in.
Company Name 46.INNER CASING OR TUBING "eotlier`iHal"eto`sed too
WM0501436 FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 35 ft. 1 ""' sCh 40 PVC
List all applicable well construction perils(i.e.County.Stale,Variance,etc.)
ft. ft. fin.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER !SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35 f`' 40 f`' 1 in. 1, 1.010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑)ndustrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
FROM TO MATERIAL; EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 f" 32 ft. cementgrout tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 32 ft- 34 ft- bentonite prepack
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19AN1))GIIAFEL3' GKfif ltcabfe �.
'
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 34 f`• 40 f` No 1 sand Prepack
ft. ft.
❑Experimental Technology ❑Subsidence Control
10.DRWLiNG LOGI.adaeh"=additional sheets if,neeessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil(rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 40 ft• silty,clayey sand
4.Date Well 5/13/2021 MW-71s)Completed: tt tt i
5.Well Location: tt. ft.
Carriage House Cleaners DSCA92-0051
Facility/Owner Name Facility ID#(if applicable)
537 Plaza Circle, Raleigh e. ft. If�g it
Physical Address,City,and Zip 21.�,Ry EM�/ARKTlS+ r 1, VIA
Wake 1711513109 100 WR_-.
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) y.isnee� ken:oPxi
35.70372 N -78.61118 w pp N:m=awrence OPPcr,o=flegiona PmNy
Lawrence O er' rK,aw I i I sm2021
an=uryeNeywnaiProm�e�om.r=us
Signature of Certified Well Contractor Date
6.is(are)the well(s): ©Permanent or ❑Temporary
By signing this form,1 hereby certify that rite 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 [KIND copy ofthis record has been provided to the well owner.
Ifiluis is a repair,fill out known well construction information and explain the nature ofthe
repair under 921 remarks section or on the hack of this f trm. 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 infection or non-water supply wells ONLY with the same construction,you cam
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 40 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdi_jferent(example-3@200'and 2@100') construction to the folloeing:
10.Static water level below top of casing: 18 approX (ft) Division of Water Quality Information Processing Unit,
if water k't-el is above casing,use"+ 1617 Mail Service Center,'Raleigh,NC 27699-1617
11.Borehole diameter: 2.25 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
direct-push above, also submit a copy of this form within 30 days of completion of well
as
12.Well construction method: p 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 Cente1r,1Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Su ply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one;copy of this form within 30 days of
completion of well construction to the county,health department of the county
13b.Disinfection type: Amount: where constructed. f
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality I Revised Jan.2013