GW1-2021-04555_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 ft. ft.
NC3322-A
NC Well ConuactorCertification Number 15:'OUTER'CASING formalti-cased:weps OR LINER ita 1cable
FROM TO DIAMETER; THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name
16.INNER CASING OR TUBLNG ige6fliifmal'doseil loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 1'. 10 ft. 1 in• sch 40 PVC
List all applicable well construction permits(i.e.County,State.Variance,etc.)
ft. ft. in.
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3.Well Use(check well use): m<17.SCRREN = gam,,.. as
Water Supply Well: FROM TO DIAMETER 1SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 fL 20 ff 1 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18,GRQU1,z._
FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 ft. Grout Our
Non-Water Supply Well: p
2Monitoring ❑Recovery 3 tt. g ic. bentonite' Pour
injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 404',SAND/GRA EPACK"ifa "licsble.__
FROM TO MATERIAL• EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
8 f° 20 ic• #2 sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
2Q.DRILLING LOG attach.add t don'� siiryl
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,wit/mck type,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 20 ft. Silty Clay over Highly Weathered Rock
4.Date Well(s)Completed:
2/17/2021 MW-4R
it. ft.
5.Well Location: ft. ft.
McCullers Walk
t
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Tawney Slope Ct. & Misty Pike Dr., Garner it. it. AP15 if
J1 lit
Physical Address,City,and Zip
Wake 4ct►r31ion ro
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: R1gi1
(ifwell field,one[at/long is sufficient) Lawre ce °Nia=�"a eOpO"° g°''
�,rrow°s x�m w.
35.661002 N 78.694788 W Opper C-us 3/2/2021
Date l031.03a2,ri S4e-0SVO'
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify then 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 [KIND cow ofthis 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 421 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: 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 ifdiftreni(example-3@200'and 2C100) construction to the follouring:
10.Static water level below top of casing: approX 12 (ft) Division of Water Quality,Information Processing Unit,
If water lcn el is above easing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.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
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13a.Yield(gpm) Method of test:. 24c.For Water SuuDly&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.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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