GW1--07490_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information: -
I4 t ATER ZONES
Lawrence D. Opper .., .•••. . K a z. ..
Mt' FROM TO DESCRIPTION
Well Contractor Name ft. ft. i
NC3322-A ft. ft. }
',15.OUTER'CASING(fir malts cased;wells OR LINER tf a '"licable
NC Well Contractor Certification Number ) f Pp
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name '16 INNER CASPIG OR TUBING(geothermal closed loop)';`, '''
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 10 ft. 1 in' sch 40 PVC
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft. ft. 1 in.
3.Well Use(check well use):
Water Supply Well: FROM TO • DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 ft' 25 , ft• 1 in.. .010 sch40 PVC
ft ft. in.:❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft.
Non-Water Supply Well: 3 cement grout pour
EMonitoring ❑Recovery 3 ft. 8. ft. bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge 0 Groundwater Remediation 19;'SAND/GRAVELPACK(rf applicable) a,t_
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 8 ft. 25 ft• #2 sand pour
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
A0:DRILLINGLOG.(attaeh additional"sheets if necessary)-' `, ,.
❑Geothermal(Closed Loop) • ❑Tracer FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,etc.) "
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• 25 ft• . , Silty Sand
9/5/2023 GPW-8R 15 ft• 25 ft• weathered rock/saphrolite
4.Date Well(s)Completed: ft• 25 ft• Bedrock Refusal
5.Well Location: ft. ft.
Former Diazit Company ft. ft.
Facility/Owner Name Facility IDtb(if applicable)
ft. ft. :•' f. r.
941 US Hwy 1, Youngsville • ft. ft. NOV g, R 2n23 • .
Physical Address,City,and Zip ,-
'ill REMARKS _" ."(4,-'A .'
Franklin 1�;;� -1z i 9 .1
County Parcel Identification No.(PIN) / / ; �=' :v�'_i i✓jJ
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: �• f`, mirs=�,e ewoef
/ DN uNaw erce Oppe,o=Reglorel
(if well field,one lat/long is sufficient) LaV1/ ce PNsem<esou
36.0342178 78 50660 Opperu5 " ,„„,,„'«• 9/29/2023
N w pp 7/ Da[ei0]1Da09151:19-09 0
Signature of Certified Well Contractor ' Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certtb,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 ONo 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 fillremarks 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 construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 25 (ft.) 24a. For'All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd(erent(example-3@200'and 2@l00') 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
Geo robe DPT above, also submit a copy of this'form within 30 days of completion of well
12.Well construction method: p 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 submit1 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. i
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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