GW1-2023-00449_Well Construction - GW1_20230109

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
Well Contractor Name ft. ft.
NC3322-A ft. ft.
NC Well Contractor Certification Number 'IS.OUTER CASING for mnld-cas4wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)'
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 1" 2 ft. 2 in. sch 40 PVC
List all applicable well construction permits(i.e.County,Slate,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 2 fe 12 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
❑Irri ation 0 ft. ft.
Non-Water Supply Well: 1 cement grout pour
1 ft- 1.5 f`• bentonite pour
ZMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 1.5 ft• 12 f`• #2 sand Prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attacb`additioiial'sheets ifnecessa K❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillr ock type,grain sin,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 it 12 fL Silty Clay over Sandy Silt
4.Date Well(s)Completed: t
12/29/2022 MW-5 ft. ft.
5.Well Location: ft. ft.
Chatham Cleaners and Launderette DSCA190002 ft ft 0 9 2023
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
401 East Third Street, Siler City
r�",Vo:J0r�
Physical Address,City,and Zip 21.REMARKS"
Chatham
Comity Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) t Dlgaita ll�yssryigp�edioyr alwprobntng0cpopme,r
D =lwree Opper.=Regtonar
-1
35.727058 N79.45980430 Lawrence Opper,
US 12/30/2022 W
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 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IUNo copy ofthis record has been provided to the well owner.
If this is a repair,fill aut 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 one form. 24.Submittal Instructions:
9.Total well depth below land surface: 12 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: approX 5 (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: 3.75 (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.)
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
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
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