GW1-2022-08321_Well Construction - GW1_20220502

WELL CONSTRUCTION RECORD For Internal Use ONLY: [
This form can be used for single or multiple wells
1.Well Contractor Information: Cd
Lawrence D. Opper AiL IWATER ZONE9�
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
I
NC3322-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells LINER(if
A "Iiciible
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. iin.
Company Name 16.INNER CASING OR TUBLNG eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft- 2 in. Soh 40 PVC
List all applicable we//construction permits(i.e.County,Slate,Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 17:-SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 f` 15 f`' 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) f� ft• in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&A.MOUNT
❑Irrigation 0 ft. ft
Non-Water Supply Well: 3 cement grout pour
OMonitoring ❑Recovery 3 rt. 4 ft bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK'(if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 fr. 15 f`• #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20:DRILLIATG LOG attach additional sheets if necessary <
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f` 15 ft silty Clay and Silty Sand
4.Date Well(s)Completed: 2/24/2022 MW-4 f` 15 f` Partially weathered rock
ft. ft.
5.Well Location:
401 Cleaners DSCA DC350001 ft ft
Facility/Owner Name Facility ID#(if applicable)
608 n. Bickett Blvd. Louisburg
Physical Address,City,and Zip 21 REMARKS
Franklin
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one]at/long is sufficient) oyaalys bylA_-opper
l- ON:cn=lavnence Opper,aaegiona
36.1039614 ,� 78.291604 W Lawrence Oppef Pro,n emice,,oe, 3/17�2022
em511=tarry@reg10 1pm ng,:.,rUS
Signature of Certified Well Contractor Date
6.is(are)the well(s): IZPermanent or ❑Temporary by signing this form,I hereby certify that the we/1(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 0No copy of(his record has been provided to the well owner.
lfthis is a repair,fill out known well construction information and explain the nature gfthe
repair under#21 remarks section or on the back q/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.
Far multiple injection or non-water supply wells ONLY with the same construction,vo i can
submit one farm. 24.Submittal Instructions:
9.Total well depth below land surface: 15 (ft.) 24a. For All Wells- Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@2700'and 1C100') construction to the following:
10.Static water level below top of casing: approX 9 (ft) Division of Water Quality,Information Processing Unit,
,y water kmel is above casing,use"+• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4.25 (in.) 24b.For iniection Wells: In addition to sending the forrn 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.) i
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cen i ter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.Fot 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