GW1--00367_Well Construction - GW1_20240112

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. O er 14:WATER ZONES "
PP FROM _ TO DESCRIPTION.
Well Contractor Name ft. ft.
NC3322-A ft. fL -
NC Well Contractor Certification Number •15.OUTER CASING(for Multi-cased wells)OR LINER(if an'Ilicable)r `
FROM TO DIAMETER! THICKNESS , MATERIAL
Regional Probing Services ft. ft. :in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop), ,
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 7,5 it 2 'in. sch 40 PVC •
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN . "' ' "
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 7.5 ft. 17.5 ft 2 in' .010 sch40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 'FROM
FR TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 it Cement pour
Non-Water Supply Well: '
OMonitoring ❑Recovery 3 ft• 6.5 ft #20 Bentonite pour
Injection Well: ft. ft
0 Aquifer Recharge 0 Groundwater Remediation19.SAND/GRAVELPACK(if a plicable)° �.: � - "
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 6.5 ft 17.5 it #2 sand prepack/pour
0 Aquifer Test 0 Stormwater Drainage -
ft. ft
❑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 size,etc.)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft 0.4 it Asphalt
•
12/12/2023 MW-1 0.4 ft 17.5 ft Silty Sand over Partially Weathered Rock
4.Date Well(s)Completed:
ft. ft.
5.Well Location: ft. ft.
Little Angels Annex ft. ft. = 1,-''''; D
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
720 S. Main Street, Fuquay-Varina ft• ft JAN 1 2 2024
Physical Address,City,and Zip 21.REMARKS •-
Wake ,,rl(h :..a ,II .. . .�� ..: :;jLr
County Parcel Identification No.(PiN) •
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one!at/long is sufficient)
) t Qy,aKa�,�.'2�ooa.
35.5753026 N 78.8006835 W Lawrence OppelkoZe °�� :° -°� 12/30/2023
Signature of Certified Well Contractor i Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with l5A 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 i
repair under#21 remarks section or on the back of this fonn. 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: 17.5 (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:
rox
10.Static water level below top of casing: approx 15 (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: 2'5 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Direct-Push above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: I
(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.
i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013