GW1-2022-06882_Well Construction - GW1_20220718

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells 'I
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1.Well Contractor information:
Lawrence D. O er ,14.►�ATEri!2ONE5' �. , .4.
pp FROM TO DESCRIPTION
Wel I Contractor Name ft. ft.
x
NC3322-A ft. ft.
NC Well Contractor Certification Number
x�aOC1TERiGASIIYiG•#or'ittulii�ased:iiells_ORl IlYER ifa "licable ...
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name IGsIIYNER;Cr4ST\ TQRYTCI$G�G "e6tlexmal.elosedloo .....a'a_ ......:
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft. 2 ft. 2 in' sch 40 PVC
List all applicable well construction permits(i.e.C'ounty,State,Variance,etc.) in ft. ft. ,
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 2 It- 17 r" 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
3.18:GRQIJT' z a;_„C F- +..a , .>. ,+,..': 3s..a ..:' ..€�'�.h:•a r,. .? ass
❑Industrial/Conunercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNTS
❑Irrigation 0 ft. 1 ft. cement grout pour
Non-Water Supply Well:
❑Monitoring ❑Recovery 1 . ft- 1.5 e• ben ,..:. .pour
Lljection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation ',-W-SAN1i1GRA4EIPAC1�ifa'"licali[c't
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1.5 It- 17 ft' #2 sand Prepack/pour
[]Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
20�DfuIi1;IN(�1�CiG Aft&cfi addttional`�sHeets:ifnecessary .'�� '��",�:„, x, .,,`�":r.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock t. e,grain size,etc.)
❑Geothemlal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fl- 17 ft. �'Silty Sand over Silty Clay
5/12/2022 MWA ft. ft.
4.Date Well(s)Completed: ft. ft.
5.Well Location: ( i,�, T
ft. ft.
Duncan Junction Depot
fL ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
12638 NC Hwy 42, Holly Springs '"t�
ft. rt �t
Physical Address,City,and Zip r ('
00"", ..f._
Wake
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i'
(ifwell field,one fatilong is sufficient) DigUllyslgnedby Lpwr-Cpper
DN:cn=rawrence Opper,o=Reglmal
35.56239 N 78.86230 W Lawrence Opper P��b�g5enl e=
�emai6larry�regio allprobtng.rom,c=US 6/7/2022
" PaVe.2a?2.86.1{.76=}bq BA'gg'
Signature of Certified Well Contractor �. Date
6.Is(are)the well(s): ©Permanent or ❑Temporary y signing f y 1i () ( )
B si Hitt Ihls form,I hereby taro deal the wells way were constricted in accordance
with 15A NCAC 02C.0100 or 15.1 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy ofdtis record has been.p,•ovided io the well owner
Ifthis is a repair,Jill oul known well consirucrion information and explain[he nature oftlre
repair under#21 remarks.seciion or on due back o(YhisJorm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For i n ltiple ityection or non-water supply wells ONLY with the same construction,you can
submit one farnr. 24.Submittal Instructions:
9.Total well depth below land surface: 17 (ft.) 24a. For All Wells: Submit this fonn within 30 days of completion of well
For naulliple wells list all depths ifdierent(example-3 200'and 2�100� construction to the following:
10.Static water level below top of casing: approX 3 (ft) Division of Water Quality,Information Processing Unit,
If baler level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.5 (in.) 24b.For Injection Wells: In addition to sending the fonn to the address in 24a
Ge0 be DPT above, also submit a copy'of this form within 30 days of completion of well
ro
12.Well construction method: p construction to die 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(gpm) 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. i
Ill
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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