GW1-2022-08333_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:
4:WA7'ER'ZUN1S'.'.
Lawrence D. Opper FROM TO I DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. rt.
NC Well Contractor Certification Number YS?,OUTE" NSING.for,tiWtrca'se8'<wells.ORLINER=tfa`"lic'able
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services rt. rt. in.
Company Name ,1 `E1Z CrCSINGr'ORwTf)BING:"eotl ernial'elosed4ori
FROM TO I DIAMETER: I THICKNESS I MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft- 2 ""' seh 40 PVC
List all applicable well emxsiruction permits(i.e.County,State,Variance,etc.)
ft.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft. 20 ft. 2 'n 010 Sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fa ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shamed)
FROM I_TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft. cement grout pour
Non-Water Supply Well:
@Monitoring ❑Recovery 3 ft. g fL bentonite pour
Injection Well: ft. it.
❑Aquifer Recharge ❑GroundwaterRemediation RIVS41±1DIG1At K 3a ]icable._. k
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
8 ft- 20 ft• #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20 DR[LLINGiI3ElG`ink ttach*additional beets ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Retwn) ❑Other(explain under 921 Remarks) 0 ft. 20 ft• silty Clay over silty Sand
2/21/2022 MW-2, MW-3 ft. ft.
4.Date Well(s)Completed: ft. ft.
5.Well Location: ft. ft.
401 Cleaners DSCA DC350001 rt— ft. -I VIC f-
Facility/Owner Name Facility IDA(ifapplicable) ft ft. -
608 n. Bickett Blvd. Louisburg MU 0 9 on
ft. rt.
i
Physical Address,City,and Zip
Franklin {;; ;n ,1 L„I T
County Parcel ldentification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) iaaysignedbyl.—we Per
� <n=+arrtence Opper,o=Regional
36.1045510 N 78.292353 Lawrence Opper emab+=any regionalpmbing.mm,c US 3/17/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certifj than the uell(s)was(were)constntcied in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consinrction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E 3No copy ofthis record has been provided to the tell owner.
if this is a repair,fill oul known well construction information and explain the nature of the
repair under H21 remarkc section or an the back ofthis 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: 2 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one Jarm. 24.Submittal instructions:
9.Total well depth below land surface: 20 A) 24a. For All Wells: Submit this form within 30 days of completion of well
Por multiple wells list all depths ifdifferent(example-3@200'and 2C100) construction to the following: -
approX 12 Division of Water Quality,Information Processing Unit,
10.Static water level below top of casing: (ft.)
/f water lei-el is above casing,use"4 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter. 4.25 (in.) 24b.For Iniection Wells: In addition to sending the form 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.)
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 pone 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 Q jality Revised Jan.2013