GW1-2022-01207_Well Construction - GW1_20220103

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
14 5t'ATER,ZONES
Lawrence D. Opper
FROM TO DESCRIPTION
Well Contractor Name ft. It.
NC 3322-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mtith easedasehs ORLINER ifa licable
FROM TO DIAMETERI THICKNESS MATERIAL
Regional Probing Services ft. ft. Iin.
Company Name 16.1NNET CASING OR INC. "eolhartrial,etos'a loo
FROM TO DIAMETER- THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 5 «. 2 in. sch 40 PVC
List all applicable hell construction permils(i.e.C'ouniy State,Variance,etc.)
ft. ft. I in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 5 «. 15 tt• 2 "' 1 .010 SCh40 I PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) «. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 tt. ft.
Non-Water Supply Well: 3 cement grout pour
MMonitoring ❑Recovery 3 rt. 4 ft. bentonite pour
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL=PACK if=a` licablE
❑Aquifer Storage and Recovery ❑Salinity BarrierFROM I TO MATERIAL EMPLACEMENT METHOD
4 ft 15 ft' #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
fr. ft. j
❑Experimental Technology ❑Subsidence Control
20:DRII.LINGI.OG attach addiHonallslefis'if iteees"sary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,gnin sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt. 1 ft. Concrete over gravel
4.Date Well(s)Completed: 11/29/2021 MW-1 1 «. 3 «. Silty/Clayey San
3 rt. 15
5.Well Location:
Circle K 2723843 ,AN
Facility/Owner Name Facility ID#(if applicable)
4470 Hwy 87 South, Sanford
r• 5 v
.s
Physical Address,City,and Zip
Lee
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification: ; otm'b w.��s
(if well field,one lat/long is sufficient) Lawrence
35.424214 N 79.120655 W Opper �wm. 12/14/2021
°t ,.,Z,.,, ,
Signature of Certified Well Contractor Date
6.Is(are)the we6(s): ©Permanent or ❑Temporary Av signing this form,I hereby certify that the tar/1(s)nas(were)constructed in accordance
with 15A NC9C 02C.0100 or 15A NCAC 02C'.0200 Well Construction Standards•and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy gflhis record has been provided to the uvll 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 gflhis 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction, it can
submil onelbrnt. 24.Submittal Instructions:
9.Total well depth below land surface: 15 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nrnhiple wells list all depths ifdierent(example-3@a 200'and 2C100) construction to the following:
10.Static water level below top of casing:
approx 11 (ft.) Division of Water Quality,'lnformation Processing Unit,
If water level is above caring,use"+^ 1617 Mail Service Cei ter,Raleigh,NC 27699-1617
11.Borehole diameter: 4.25 (in.) 24b.For infection Wells: In addition to sending the form 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 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.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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