GW1-2021-04352_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name Or� ft. ft.
NC3322-A
NC Well Contractor Certification Number
� s5 15.OUTER CASING'for multi cased wells OR LINER if a `Iicable ;
P. Q`Q FROM TO DIAMETER THICKNESS �•tATER1AL
Regional Probing Services �` Sg rt. ft. in.
Company Name pp ( ^16.'INNER CASING.OR TUBING eoihefmal el6sed400 a..
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 25 ft. 2 i" Sch 40 1 PVC
List all applicable well construction permits(i.e.Couay Stnte,Variance,etc.)
ft. ft. in.
3.Well Use(check well use):
47.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 25 rt 35 it' 2 in. .010 sch4 PVC
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 rL 3 ft. cement grout pour
Non-Water Supply Well:
[a Monitoring ❑Recovery 3 R. 23 e. bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL-P<ACK ifs licable`.","
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 23 ft• 35 it' #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
-.20.DRILLING LOG attach iddifiondl`sheets if eecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,willrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 rt• 35 ft. Brown Sandy Silt
4.Date Well(s)Completed:
1/22/2021 MW-1 f. ft.
ft. ft.
5.Well Location: ft. ft.
ABB
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
6801 Industrial Drive, Mebane
Physical Address,City,and Zip 21 REMARKS
Q f cqn Dy2.
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) D I[aly signed 6y Lawren eOpper
DN:cn=Wwrence Oppe-Regional
Lawrence Opperee ^�m�e9;o�prob;ngmn,��s 2/10/2021
36.08040 N 79.23409 W
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ©Temporary By signing this form,I hereby certify that the uvll(s)uas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC AC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KlNo copy ajihis record has been provided to the well owner.
ff 1his is a repair,fill out known well construction information and erplabt the nature of the
repair under#21 remarks section or on the back gfthis ji>rm. 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,Yon can
submit one farm. 24.Submittal Instructions:
9.Total well depth below land surface: 35 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
ff uater kn•el is above easing.use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
i I.Borehole diameter- 2.25 (in.) 24b.For Infection 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 Suably&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.
Fonn GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013