GW1-2021-03061_Well Construction - GW1_20210624

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: C
Lawrence D. Opper 4 2021 FR WATER ZONES.
.
„tl\� FROM TO DESCRIPTION'
Well Contractor Name g51f19 watt ft. ft
NC3322-A atlon Ptoce on 7 fr. rt
NC Well Contractor Certification Number 100T. pV4R SgCr 15.OUTER CASINIG,foc multi cased w61is OR 3.TNER�if a licablel __IJ
FROM TO DIAMETER: THICKNESS MATERIAL
Regional Probing Services e. ft. I in.
Company Name 16.INNER CASING OR TU LNG `'eothermal elo5id loo
WM0701248 FROM TO DIAMETER' THICKNESS 'MATERIAL
2.Well Construction Permit#: 0 ft' 15 ft. 1 in. Soh 40 PVC
List at/applicable well construction permits(i.e.County.State,Variance,etc.)
in.
3.Well Use(check well use): 17.SCREEN "
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 rt. 20 ft' 1 in.
020 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT,
FROM I TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 f" 12 ft. Grout tremie
Non-Water Supply Well:
❑+Monitoring ❑Recovery 12 ft• 14 ft• Bentonite prepack
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 49.SAND/GRAVES PACK ifs"livable'
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 14 ft tr.. 20 No 1'sand Prepack well
ft ft.
❑Experimental Technology ❑Subsidence Control
20:DRIIyLINCLOG.attachjid7ifionals`hee6iffoee`essa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock h e gnin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt' 20 ft. Sllty Sand
5/17/2021 ft. ft.
4.Date Well(s)Completed: �
ft. ft.
5.Well Location: ft. ft.
Oak Trail Solar, LLC
Facility/Owner Name Facility ID#(ifapplicable)
Puddin Ridge Road, Moyock
Physical Address,City,and Zips
21.1iEMARKS"
Currituck MW-1(N36.507617,W76.203791);MW-2(N36.504781,W76.176977
County Parcel Identification No.(PIN) MW-3 N36.490314,W76.199306)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/iong is sufficient)
see 21. ,,is
Lawrence O errs W
N �, pP �� o,aa.,.��h�+ 6/10/2021
Signature of Certified Well Contractor¢9-0 Date
6.Is(are)the well(s): ©Permanent or ❑Temporary signing this form,1 hereby cent that the well(s)was were constructed in accordance
H3'�$ K I J' !y' j ! )
with 15A NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy ofthis record has been pr oyidcd to the well owner.
lfthis is a repair,fill out known well construction information and explain the nature oflte
repair under#21 remarks section or on the back ofdiis.irrm. 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: 3 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,yarn can
submit oneform. 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 ifdifferent(example-3Q200'and 2@100D construction to the following:
i
10.Static water level below top of casing: <5 (ft.) Division of Water Quality,Information Processing Unit,
//'water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2.5 (in.) 24b.For Infection 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.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centel,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test:. 24c.For Water SUDDIV&Geother Ia]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. s
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013