GW1--07495_Well Construction - GW1_20231120

WELL CONSTRUCTION RECORD For Internal Use ONLY: 1.
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. O er 14.WATER ZONES -, ',. _ ,
PP FROM TO DESCRIPTION
Well Contractor Name ft• ft.
NC3322-A ft. ft. 1 '
NC Well Contractor Certification Number 15.OUTER CASING.(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER THICKNESS MATERIAL .
Regional Probing Services ft. ft. ; in.
Company Name ?16.INNER CASING OR TUBING(geothermal closed-loop)Tr.
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): 17�SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
•❑Agricultural ❑Municipal/Public 5 ft. 15 ft. 2 '"' 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
❑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 0 Groundwater Remediation "19.SAND/GRAVEL PACK`(if applicable)`^"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 4 ft. 15 ft #2 sand Prepack/pour
ft. ft.
❑Experimental Technology ❑Subsidence Control -20_DRILLING LOG(attach addItional sheets if necessary) ''''
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardnesi,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 15 ft. Silty Sand over hard Sandy Clay
10/15/2023 MW-D,MW-E,MW-F ft. ft.
4.Date Well(s)Completed: ft. ft.
5.Well Location: ft. ft.
Circle K Store 2723022 ft. ft. -t,
Facility/Owner Name Facility ID#(if applicable)
ft. ft
2326 Owen Drive, Fayetteville ft. ft. NOV 2 0 2023 _-
Physical Address,City,and Zip 21.REMARKS "r <
Cumberland 1 C>',:.c. ,'SX-1
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: J .
(if well field,one lat/long is sufficient) I'Df•�+Ilysynedby Lawrence Opper
ID.cn=lawrence Opper,o=Reglonal
35.01923408 N 78.916706 W Lawrence Oppe,r� use c: nalprubingcom,c DS 11/6/2023
Dal..2021.02.11 1S3M1.70 05'00'
Signature of Certified Well`Contractor I Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certfy 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 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-3 200'and 2@l00') construction to the following: 1
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 Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4'5 (in.) 24b.For Injection 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: 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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