GW1-2021-03234_Well Construction - GW1_20210624

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
zo)vE
Lawrence D. Opper rawtAxER . .... :...
FROM TO DESCRIPTION.
Well Contractor Name
ft, ft.
I '
NC3322-A ft. ft. �.
NC Well Contractor Certification Number 45.OUTER"CASING for multi asesl,we]6,'ORLANER if a"`7icable
FROM TO DIAMETER' I THICKNESS MATERIAL
Regional Probing Services
Company Name 4,,16 INNEWCASING"OR[EIBIYG flfeiithi to"al°dosed loa
FROM I TO DIAMETER; THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 35 ft. 1 �in•' S'ch 40 PVC
List all applicable well construction permits(i.e.C'ounty,State,Variance,etc.) ft. ft. in.
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3.Well Use(check well use): �17.'SCREEN.._
Water Supply Well: FROM TO DIAMETER 'SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35 ft' 40 ft 1 '"' '; 1.010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL i EMPLACEMENT METHOD&A-MOUNT
❑brigation 0 ft. fL
32 cement grout tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 32 tt 34 ft bentonite prepack
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation ;�19..SiSl�WGIlAYEt 1'AC -41fa` lieallt �
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 34 ft• 40 ft• No 1 sand Prepack,pour
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
5 201DItIIsLTNG.7:(SO�artach`addtt,otial�leets if necessa.❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardness,soil/rock is a lain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 40 isilty,clayey sand
rt. ft.
4.Date Well 5/13/2021 MW-61s)Completed: tt. ft.
RECEIVE
5.Well Location: ft. ft.
Carriage House Cleaners DSCA92-0051 AI
Facility/Owner Name Facility ID#(if applicable) I V
ft. ft.
537 Plaza Circle, Raleigh rt. rt. injunnation Processinit
Physical Address,City,and Zip
211•REMAI2K5 .__ _ ;���-._.
Wake
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) wV.meoppe,
N:nr-Lawrence Opp a=aegional Probing
35.70408 N 78.61156 W Lawrence Opper` _;a,ry@fe9, I bng<om.1 sni2021
Signature of Certified Well Contractor I Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this firm,I hereby certify that the st•ell(s)seas(were)constructed in accordance
with 15A NCAC 02C.0100 a•!5.4 NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No cops ofthis record has been provided to the well owner.
Ifthiv is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarkv section or on the back of this.1brm. 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: construction details. You may also attach additional pages if necessary.
I or multiple injection or non-water supply wells ONLY with the same construction,you can
submit one farm. 24.Submittal Instructions:
9.Total well depth below land surface: 40 (ft.) 24a. For All Wells: Submit this forth within 30 days of completion of well
For multiple wells list all depths ifd ereni(example-3@200'mnd 1C100') construction t0 the following:
15approx Division of Water Quality
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10.Static water level below top of casing: (ft.) Q ty;Information Processing Unit,
1f water level a above casing.use"+" 1617 Mail Service Center,'Raleigh,NC 27699-1617
11.Borehole diameter: 2.25 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
direct-push above, also submit a copy of this fo6m 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,l Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Geotherm it Wells:fln addition to sending the form to
the address(es) above, also submit one:copy of this form within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed.
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Form GW-1 North Carolina Deparvnent of Environment and Natural Resources-Division of bYater Quality' Revised Jan.2013