GW1-2021-04557_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.-NiVATER ZONES,, ,
Lawrence D. Opper
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A
NC Well Contractor Certification Number I5.'OUTER CASINO for.multi cased Wills`OR LINER'if a usable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services
Company Name I&INNER CASING OR t IIBING. eotfie'final closed too _.•:, cg
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 tt. 23 ft. 2 in. sch 40 PVC
List all applicable well construction permits(i.e.('ounry.State,Variance,etc.)
ft. ft. I in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER !SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 23 ft. 38 tt. 2 "' ' .010 SCh40 PVC
❑Geothenmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. tt. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
18�-,GROUT ....
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑trri ation 0 rt' 3 ft• cement grout pour
Non-Water Supply Well:
OMonitoring ❑Recovery 3 ft. 20 tt• bentonite pour
Injection Well: ft. ft.
SAND7❑Aquifer Recharge ❑Groundwater Remediation CK ifa listite a- .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
20 38 #2 sand Prepack/pour .
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
:20.DRILLING;LOG attach additional heets;ifA cessary„
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,willrock t e, rain sit'-'tc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 38 tt• Sandy Silt
4.Date Well(s)Completed:
3/17/2021 MW-2R
ft. ft.
5.Well Location: ft. ft.
Han-Dee Hugo#51 ft. ft.
Facility/Owner Name Facility ID#(if applicable)
1350 Old Apex Rd., Cary ft. ft.
Physical Address,City,and Zip Unit
Wake U
1 C r
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) Lawrerle
-.Prodng Services ou,
35.771739 N 78.80795 W Opper "" ' 4/13/2021
Datr.303106.1318:SC31-0C•00'
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify tha(the well(s)it-as(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 If ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No copy ofthis record has been provided to the well owner.
Ifihis is a repair,fill out known well consiniction htformation and explain the nature ofthe
repair under 421 remarks section or on the back of this firm. 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.
Tor multiple injection or non-water supply wells ONLY with the same construction,you can
24.Submittal Instructions:
submit one farm.
9.Total well depth below land surface: 38 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For midliple wells list all depots ifd &rent(example-3@200'and 2C100) construction to the followring:
10.Static water level below top of casing:
—30 (ft.) Division of Water Quality,Information Processing Unit,
if water level is above casing,use'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
I L Borehole diameter: 4.5 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Auger 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 Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fonn within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
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Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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