GW1--07487_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
14.WATER.ZONES . _ , ,'6 x_.., r. .., r ._ ` .._.;,
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name ft. ft. i
NC3322-A ft. ft.
NC Well Contractor Certification Number .IS OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft ft. in.
Company Name I6.INNER CASING OR TUBING'(geothermaticlosed-loop)=�- , z _
W10600245 FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: o ft• 15 ft 2 1 1°' sch 40 PVC
List all applicable well construction permits(i.e.Counry,State,Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN ,,, <, .„ _t
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft 20 it 2 1°' .010 sch40 PVC
0 Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I8=GROUT= .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 12 it cement grout tremmie
Non-Water Supply Well:
❑Monitoring DRecovery 12 it 14 ftbentonite prepack
Injection Well: v ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 14.SAND/GRAVEL PACK(if applicable) ".• • .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 14 ft 20 it No2 Sand prepack
❑Aquifer Test ❑Stormwater Drainage
ft. ft. , •
❑Experimental Technology OSubsidence Control
'20_DRILLING LOG(attach additional sheets ifnecessary)•._ .,' - nab. '•
0 Geothermal(Closed Loop) 0 Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 20 ft. Orange silty Clay over tan-brn silty Sand
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4.Date Well(s)Completed:
10/18/2023 AS-1 ft• ft.
ft. ft.
5.Well Location: ft. it .- -
Smith No. 2 NCDEQ Incident No.15454 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. N O V 2 9 2023
1007 South Clinton Ave, Dunn
ft. ft.
Physical Address,City,and Zip n ',;;j
,,21 REMARKS .. ,, - , .
Harnett !S
Air-Spurge Well
County Parcel Identification No.(PIN) i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ...Am
(if well field,one lat/long is sufficient) 22.Certificatio �� DI a Sir llys9ned by Wwrence Opper
DN,n=lawrence opper•o=Reglonal
35.299143 N 78.614989 W Lawrence •pp fre,blFgs,.re9;nalpn b,ng.com r D5 11/6/2023
eot,.2oi9.o2.oao9.)os2 OM'Signature of Certified Well`Contractor i Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certtP that the well(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 ONo copy of this 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 1121 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
8.Number of wells constructed: 1 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: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dillerent(example-3 a(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: 4'5 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
AugerDP above, also submit a copy of this form within 30 days of completion of well
Auger,
DP 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.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water,Quality Revised Jan.2013
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