GW1-2022-01149_Well Construction - GW1_20220103

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
%14:WATER Z45Kf5,' r
Lawrence D. Opper
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A rt. ft.
NC Well Contractor Certification Number 15,OUTER CASING'focmi iti-cased wells OR LIl�ER if a `7icable '
F
ROM DIAMETER THICKNESS MATERIAL
Regional Probing Services It. in.
Company Name
OR TUBING eottierriiel closed-loo
DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. 2 in' Soh 40 PVC
List all applicable,cell construction permits(i.e.County,Slate,Variance,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft- 10 ft' 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ,.18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 2 ft• cement grout pour
Non-Water Supply Well:
MMonitoring ❑Recovery 2 ft. 3 it bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK i ii licalil'e`
FROM TO MATERIAL 1 EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
3 10 #2 sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
226.DRI);LINC I'da"tiffik i 6dditionalisheets if ne Essary -`_
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiLtmek type, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 10 ft Tan/reddish brown Sandy,Silty Clay
4.Date Well(s)Completed:
12/1/21 MW-27R,MW-28R
ft. ft.
5.Well:Location: ft. ft.
T-Mart#9 Incident#92446
Facility/Owner Name Facility ID#(if applicable)
ft. ft. !
1100 North Ellis Avenue, Dunn 29334 ft. ft. 3
Physical Address,City,and Zip
73i.REMARKS''
Harnett t,
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(ifwell field,one ladlongissufficient) LaW 1—.9Se-c u
'emaira, a�wuiwedre.can.
35.319365 N 78.607892 W Opper °e;o,n,,,,,�,r_�,� 12/14/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By:signing this form,I hereby certify rind the tvell(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC.01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofdtis 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 tinder 921 remarks section or on the back of this fr)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: 2 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,ymr can
submit one.form. 24.Submittal Instructions:
9.Total well depth below land surface: 10 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
1-or multiple wells list all depths if different(example-3@200'and 1C100) construction to the following:
10.Static water level below top of casing: approx. 6 (ft) Division of Water Quality,Information Processing Unit,
1f water keel is above casing.use"+'• 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter, 4 (in.) 24b.For Inketion Wells: in addition to sending the form to the address in 24a
Geoprobe 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 Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test:. 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submitione 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013