GW1-2022-08973_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD For IntemaI Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. Opper 14.WASTER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft• I,
NC Well Contractor Certification Number 15.OUTER CASING,far multi-cased,wells ORLINER ifa`licable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name 16.iNNER CASING:ORTUBING eotliermal dosed-loop),,'
WM0501497 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 29 ft. 1 i"• SCh 40 PVC
List all applicable well construction permits(i.e.County,State,Yariance,etc.)
ft. I ft. in.
3.Well Use(check well use): :11 SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 29 .f" 39 ft. 1 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) =ts.GROUT
FROM TO MATERIALEMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft.
Non-Water Supply Well: 5 cement grout pour
5 rr. 27 r`• bentonite pour
IZMonitoring ❑Recovery
Injection Well: ft. fL
❑Aquifer Recharge ❑Groundwater Remediatiori '19:SAND/GRAVEL SACK if iIiplicable
LA
❑Aquifer Storage and Recovery []Salinity Barrier
FROM TO f` MATERIAL EMP CEMENT METHOD
f`
❑Aquifer Test ❑Stormwater Drainage 27 39 #2 sand pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
2t1,DRIILINGLOG:attach additional sheetsif necessary)
s
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiVrock type,grain size,etc.)
.µ
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft. 20 ft. Silty Sand
7/21/2022 MW-25 20 f`• 39 f`• weathered rock/saphrolite
4.Date Well(s)Completed: ft. ft.
5.Well Location: fr. ft.
i ..
Former Diazit Company ft. ft. _
Facility/Owner Name Facility ID#(if applicable) _
ft. ft.
941 US Hwy 1, Youngsville ft. ft. InVolfni;,,:<-Da FlrDc*a !,ng Ursa
Physical Address,City,and Zip 21 RREMARKS
Franklin
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 9ita°Yv w9VdbyL 0PW
(if well field,one Iattlong is sufficient) Law en l_e �a
os:izwerceoRR r,o=RNIawl
t,erobny semces,w,
36.026807 N 78.502377 `l, Opper �f Da e30]]�809155P'49-0W7 8/9/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this 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 921 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same contractor,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 39 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (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: 2.5 (in.) 24b.For Injection 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.) 4
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 submitl,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-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013