GW1-2022-01150_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:
Lawrence D. Opper %14.WATER,ZONES_
FROM TO DESCRIPTION
ft. ft.
Well Contractor Name '
NC3322-A
NC Well Contractor Certification Number 15.OUTER CASING'for multi cased wells OR LINER if a 'licable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services rt. ft. in.
Company Name 16.INNER CASING'OR TUDING, eothe`itiriaLelos`ed]ob
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 tt. 10 ft. 2 '"' sch 40 1 PVC
List all applicable well construction permits(i.e.C'ounty,Smte,Variance,etc.)
ft. ft• in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER 'SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 tt. 25 ft. 2 in.
.010 sch40 PVC
❑Geothenmal(Heating/Cooling Supply) ❑Residential Water Supply(single) tr. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) aSrGROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irl ation 0 ft. ft
Non-Water supply well: 3 cement grout pour
MMonitoring ❑Recovery 3 rt. g rt. bentonite pour
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAYEL%PACK if=ii6 licable '�
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 8 ft' 25 ft' #2 sand Prepack/pour
ft. I tr.
❑Experimental Technology ❑Subsidence Control ?Q,DRILLING LOG attach addidonal sheets,if.necessar` ,
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardness,soil/rock h•e, ;;in sir,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ff 15 tt Silty Clay
4.Date Well(s)Completed: 11/22/2021 MW-5 15 fc• 25 ft• Silty Sand
ft. rt.
5.Well Location:
Harvey's Grocery
Facility/Owner Name Facility ID#(ifapplicable) k. ft. 2
3160 US Hwy 421 N, Lillington ft.
Physical Address,City,and Zip
REMARKS JAN
Harnett
County Parcel Identification No.(PIN) , ,_ G U1sJ`
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification
(if well field,one ladlong is sufficient)
IWlly slgneA by lnwrence'Opper
DN:cn=lawrente Opper,o=Regional
35.414194 N 78.868796 W Lawrence Oppef-,m'bing"wicm.o� 12/3/2021
emEll=lany�regionalprobing.cn c=us
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify thcw the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NC.AC 01C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the[cell owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back q/'this fitrm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.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,you can
snhmit one.farm. 24.Submittal Instructions:
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudtiple wells list all depths ifdiftrent(example-3�ya 200'and 2C100) construction to the following:
i
10.Static water level below top of casing: 20 (ft-) Division of Water Quality,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.25 (in.) 24b.For Iniection Wells: In addition to sending the fonn to the address in 24a
Geoprobe 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 Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
136.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