_Well Construction - GW1_20230315 (41)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
.14.WATER ZONES ,
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
NC3322-A ft. &
NC Well Contractor Certification Number A5.OUTER CASING;for multi-cased wells OR LINER if a "licable
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. f, I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 13 It' 1 in' sch 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft. I ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 13 ft' 28 ft. 1 in. .010 sch40 PVC
❑Geotheral(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft in.
m
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT"
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. ft
Non-Water Supply Well: 3 cement grout pour
IZMonitoring ❑Recovery 3 ft. 11 ft- bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL>PACK if applicable
FROM TO MATERIAL EMPLACEMENTMEIHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 11 ft 28 ft' #2 sand pour
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG."attach addi6onalsheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUrock type,grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 28 ft Silty Sand over saphrolite
2/14/2023 MW-2 MW-3 ft. ft [;
4.Date Well ,s)Completed: ' ' r
ft. ft.
MAR
-A -• �nPn
5.Well Location: ft. ft iAR LI LJ
Dutton Family Property ft. ft __ •,_.,.,_.__ ,
Facility/Owner Name Facility ID#(ifapplicable)
200 Vandora Springs Road, Garner 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 renee
: aim"r °emaM°wo'
(ifwell field,one lat/long is sufficient) L 4i°Nia a"erceO�°'•°=ate'° '
35.71208456 N 78.6223029 W Opper 3/2/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certly,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 ElNo copy ofthis record has been provided to the well owner.
1f 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
S.Number of wells constructed: 2 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construefifin,you can
submit oneform. 24.Submittal Instructions:
9.Total well depth below land surface: 28 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: 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: 2.5 (in.) 24b.For Iniection 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-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013