GW1-2021-02464_Well Construction - GW1_20210809

I
WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells
1.Well Contractor information:
Lawrence D. Opper 'AFRO�;TERZ dr�Es:. DESCRIPTION\''
Well Contractor Name ft. ft.
NC3322-A
NC Well Contactor Certification Number 45.OUTER CASING for multi cased wells OR LINER if a 'usable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. I in.
Company Name '76.INNER CASINGI'OR Ttl LNG eotherina]closed-loop)
FROM TO DIAMETER THICKNESS >tATERIAL
2.Well Construction Permit#: 0 ft. 5 ft. 2 in. Sch 40 PVC
List all applicable hell construction permits(i.e.County,.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): i7.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS DtATER1AL
❑Agricultural ❑Municipal/Public 5 `t' 15 "' 2 in. .010 Sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 3 ft. cement grout pour
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft 4 " bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL:PACK(if,'applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier tt, ft.
4 15 #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
tr. tr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG t attachadditional iheets'if necessa "
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 15 silty Clay over silty Sand
4.Date Well 6/21/2021 MW-5Rs)Completed: ft. ft.
A
5.Well Location:
Former Scotchman#26 rt. ftTVA
Facility/Owner Name Facility ID#(if applicable) 11 r `♦
ft. ft. 11C1 14
500 Bunce Rd., Fayetteville
1p coces
Physical Address,City,and Zip 21.REMARKS
Cumberland
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certificatio eeoyia.�a, Oppa,
(if well field,one ladlong is sufficient) enceOpp-. Resm,wi
35.057768, -79.003038 35.057768,-79.003038 Lawrence Opp A�on
,°amm,`as,o%y�b�9mm.�Ds 7/12/2021
N W table.
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby cert/f}'dtai the we/l(s)was(were)constructed in accordance
with 15.4 NCAC 01C'.0100 or 15.9 NCAC,01C'.0100 Well Constrtc•rion 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.
!f finis is a repair,fill out known well construction information and explain the nature of the
repair under 1111 remarks section or on the back o/'this/brm. 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-wolcr supply wells ONLY with the same construction,ynn can "
submit one form. 24.Submittal instructions:
9.Total well depth below land surface: 15 24a. For All Wells: Submit this;form within 30 days of completion of well
Fo multiple wells list all depths ifd,&rent(example-3@200'and 2C100') construction to the following:
10.Static water level below top of casing:
approx 10 Division of Water Quality,Information Processing Unit,
(ft.)
1/water level is above casing.use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4.25 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Au DP above, also submit a copy of this form within 30 days of completion of well
er,
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(gym) 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.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013