GW1--07494_Well Construction - GW1_20231120

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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. 'I
NC3322-A ft. ft.
I5.OUTER CASING(for multi-cased`wells)OR LINER(if ap.licable)
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL
Regional Probing Services ft. ft. in.
Company Name 16.INNER CASING:OR TUBING(geothermal closed-loop) "-° - ' ,..
FROM _ TO DIAMETER THICKNESS MATERIAL
2.Well Construction'Permit#: 0 ft' 5 ft. 2 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):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 it. 15 rt. 2 1°' 010 SCh40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft, ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft.
Non-Water Supply Well: 3 cement grout pour
Monitoring ❑Recovery 3 ft. 4 ft• bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation ,19.SAND/GRAVEL PACK(if applicable) o„ '
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
#2 sand Prepack/pour
o Aquifer Test 0 Stormwater Drainage
4 ft, 15 ft,
ft. ft.
❑Experimental Technology ❑Subsidence Control •
"20.DRILLING LOG(attach additional sheets if necessary) +' ! ,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under#2I Remarks) 0 ft. 15 ft. Silty Sand over hard Sandy Clay
ft. ft.
4.Date Well(s)Completed: 10/15/2023 MW-D,MW-E,MW-F F__ _. - - ,ar
ft. ft. 1i.-,.
5.Well Location: .ti,. )'% •; �-„
ft. ft.
Circle K Store 2723022 ft. ft. NO V 2 t 2023
Facility/Owner Name , Facility ID#(if applicable) ft ft r
no:;„,a•:.'�.i1 ✓r n,'1n;,,y i -."
2326 Owen Drive, Fayetteville ft• ft, U',' C:2, ,_4
Physical Address,City,and Zip -
71:REMARKS _ ,. .e
Cumberland -
County Parcel Identification No.(PIN) '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) 01gItaltyslgnedbyLawence0pper
35.01923408 78.916706 pp DN:cn=se-, ceepper,o=Regional
N W Lawrence O er•erobing Service;op, 11/V/2023
mall17.:21onn'.`i ng.mm,"us
Date.2021.02.11 1904.19 0500'
Signature of Certified Well'Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certib,that the well(s)was(were)constructed in accordance
with 1SA 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#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: 3 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: 15 (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 a/�00'and 2@100) construction to the following:
10.Static water level below top of casing approx 10 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service 1Center,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 DP above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: r 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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