GW1-2022-10797_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: a
14;WA CER ZOi �s.
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name ft. ft f
NC 3322-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR L[NER �f a licable
FROM TO DIAMETER THICKNESS. MATERIAL
Regional Probing Services ft. ft. ! in.
Company Name 16.INNER CASING OR TUBING 'e6thermal closed-loo `
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 1" 17 ft' 2 1 in. sch 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft. ft. I' in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO J.DLAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑MunicipaYPublic 17 It' 32 r" 2 'n I .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
❑hTi ation 0 ft. it
3 cement'grout pour
Non-Water Supply Well:
lDMonitoring ❑Recovery
3 ft. 15 ft, bentonite pour
Injection Well: Its ft.
• r
❑Aquifer Recharge ❑Groundwater Remediation I9.SAND/GRAVEL PACK if a licable
FROM TO I MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Sallrilty Barrier
❑Aquifer Test ❑Stormwater Drainage 15 ft. 32 ft #2 sand Prepack/pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.:DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 32 ft. Silty Sand over weathered rock/saprolite
10/25/2022 M W-5 ft. ft.:
4.Date Well(s)Completed
ft. ft.
5.Well Location: ft. ft.
Honeycutt Cleaners ft. ft.
Facility/Owner Name Facility ID#(ifapplicable)
ft. f
t. 1fTi?�raf:o•',�,�q �.-.
eZ71di..L'
605 New Bern Avenue, Raleigh ft. ft
Physical Address,City,and Zip 21.REMARKS
Wake
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: G p9ta9r99 dMLmvmrc 0e W
(ifwell field,one lat/long is sufficient) Lawrence
`emaa=n�yo,evm,aiw9�om
35.780474 N 78.628785 W Opper Da eZ9]3Ad)181349-059P 11/17/2022
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 15A NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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#21 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 ofwells constructed: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit oneform. 24.Submittal Instructions:
9.Total well depth below land surface: 32 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: approX 23 (ft) Division of Water Quality,Information Processing Unit,
ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4.5 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger 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
131b.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