GW1-2022-06883_Well Construction - GW1_20220718

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
44.WATER ZONES `
Lawrence D. Opper FROM To DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft.
NC Well Contractor Certification Number IS:OUTER CASING for multi eased' ells)°OR LIl�ER-ifa liCable
R16ANNER
TO DIAMETER THCKNESS MATERIALRegional Probing Services ft. in.Company Name ASING OR TUBING eothermal closed loo ,rTO DIAMETER THICKNESS ;MATERIAL
2.Well Construction Permit#: 3 f`• 2 �'";' sch 40 PVC
List all applicable well consintction permits(i.e.County,State,Variance,etc.)
ft tt
3.Well Use(check well use): �A,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIALry^
❑Agricultural ❑MunicipaUPublic 3 ft. 18 f`. 2 1D' .010 -sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. f`. in.
❑IndustriallCommercial ❑Residential Water Supply(shared) 18"GROUT ,G FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 1 ft. cement grout .pour
Non-Water Supply Well:
2Monitoring ❑Recovery 1 ft. f`• bentorlite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAS?EL-PACK ifa livable" ['
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
2 f` 18 f` #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
;:'20."DRILLING`LOG attach additi6nal°sheeis,if'neeessary e
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness sorUrock ty e rain sae,etc.)..
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 18 ft. i Silty Clay
5/12/2022 MW-2 MW-3 ft. rt.
4.Date Well ,s)Completed: ft. ft. 1i
5.Well Location: ft. ft. I d " ° ^'
Duncan Junction Depot ft. ft. 'JUL
FacilitytOwner Name Facility ID$(if applicable) ft. ft.
12638 NC Hwy 42, Holly Springs
Physical Address,City,and Zip
21-REMARKS. _ 3i r,lJrilti
Wake
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(iFwell field,one ladlong is sufficient) (:DigUlysigned by'Lawrence Opper
35.56239 78.86230 ON:a amerce Opper.o Regtowl
Lawrence Opper�e�b��gseN��e,,o�, i sn/2o22
N W .emzn=larty�reglanalprobing.mm c=US
Signature of Certified Well Contractori Dale
6.is(are)the wcll(s): Permanent or ❑Temporary y 8 8 f y h O ( )
R si min this arm,1 hereb•certi trod lha u•el/s uas were constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell C.'onstnnvion.Standards and that a
7.is this a repair to an existing well: ❑Yes or E3No copy ofthis record has been provided to the well owner.
Ijthis is a repair,fill art known n•ell construction information and explain file native ofthe
repair larder#21 remarks section or on the back ofthisform. 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.
ror nudtiple injection or non-water supply wells ONLY with the same construction,yotr can
submit one farm. 24.Submittal Instructions:
9.Total well depth below land surface: 18 (ft.) 24a. For All Wells: Submit this fortis within 30 days of completion of well
ror multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: approx 5 (ft) Division of Water Quality,Information Processing Unit,
IJ'uater 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 form to the address in 24a
Ge0 robe DPT above, also submit a copy of this form within 30 days of completion of well
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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Suyyly&Geothermal Wells: In addition to sending the form to
the address(es) above,also submit onej c6py 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
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