_Well Construction - GW1_20230315 (43)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
A4.WATER ZONES
Lawrence D. OpperFROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. I in.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 3 ft. 2 in• sch 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc)
ft. f[. in
3.Well Use(check well use): 17:SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 ft. 18 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) El Residential Water SuPPIY(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. ft
Non-Water Supply well: 1 cement grout pour
OMonitoring ❑Recovery 1 ft- 2 ft- bentonite pour
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 2 ft- 18 fr. #2 sand Prepackipour
ft. f[.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain sin,ete.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 18 ft. Silty Clay
3/23/2023 MW-4, MW-6 ft. ft.
4.Date Well(s)Completed: ft, ft.
5.Well Location: ft. ft. _
Duncan Junction Depot it. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
12638 NC Hwy 42, Holly Springs f. f� MAP
Physical Address,City,and Zip
21.REMARKS
Wake ,
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) Igltallysigned by Lawrence Opper
DN:rn=lewrence Oppet o=Reglonal
35.56239 N 78.86230 w Lawrence Opper e1ingse,i-,oa, 3i6(2023
it=larry@region Ipmbing.com,c=US
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
I with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IDNo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#11 remarks section or on the back of 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
S.Number of wells constructed: 2 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 18 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(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,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.5 (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
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.
Font GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013