GW1--07491_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
. This form can be used for single or multiple wells ,
1.Well Contractor Information: l
;°14:WATER ZONES. ...
Lawrence D. Opper FROM TO DESCRIPTION
Well Contractor Name' ft. ft. 1
NC3322-A ft.• ft. i
NC Well Contractor Certification Number -IS:OUTER.CASING(forth ilti-ased;walls)()MINER(if ap'licable) ''
FROM TO DIAMETER' THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name 'd16:INNER CASING OR TUBING(geothermal closed loop), E.. ,.
FROM TO DIAMETER: THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 20 ft. 1 in. sch 40 PVC
List all applicable well construction permits(i.e.County,State,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 20 ft. 30 ft 1 . tn' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in. '
❑Industrial/Commercial ❑Residential Water Supply(shared) 18'GROUT ,4 ;,k -. ., �, - -.P. ,_,'s
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft• 3 ft' cement grout pour
Non-Water Supply Well:
21Monitoring ❑Recovery •
3 ft. 18 ft bentonite pour
Injection Well: • ft: ft.
❑Aquifer Recharge ❑GroundwaterRemediation • »19_:•SAND/GRAVEL PACK'(ifapplicabli),.. ., -
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 18 ft• 30 ft #2 sand. pour
❑Aquifer Test ❑Stormwater Drainage -
ft: - ft. .
DExperimental Technology ❑Subsidence Control
20:DRILLING-LOG(atsadi adHtiona1 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• 10 it Silty Sand
9/5/2023 GPW-4R 10 ft• 25 ft weathered rock/saphrolite
4.Date Well(s)Completed: ft: 30 ft Bedrock Refusal
5.Well Location: ft. ft. _
Former Diazit Company ft. ft. ..: ;_. ,;`
Facility/Owner Name Facility ID//(if applicable) ft. ft.
941 US Hwy 1, Youngsville ft: ft NOV ,�2�
Physical Address,City,and Zip 21.REMARKS,x, + . , k,.'r,g .,,, ? ,„-.
Franklin . 1:. ; ._.c•1_s
County Parcel Identification No.(PIN) ,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: t'DlybtYa9ned Mlawrer,ce0pper
(if well field,one lat/long is sufficient) • e j CM lawrerceOpper,o=Regional
' /emadnre Raeglonalprobng<our,
36.036355 N 78.50348 W •
Opper t y Dat::7:0 09,„,:,,...V 9/29/2023
Signature of Certified Well Contractor '' Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certtry that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENo 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 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: 30 (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@100') construction to the following: I
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.)
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 lone 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. ^f
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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