WI0600245_Well Construction Record(s) (GW-1)_20231122

WELL CONSTRUCTION RECORD'FCr�VED
This form can be used for single or multiple wells NOV G 1. Well Contractor Information: NO Y 2 2023
Lawrence D. Opper
Well Contractor Name '
NC3322-A Cenh* Office
NC Well Contractor Certification Number
Regional Probing Services
Comparry Name
2. Well Construction Permit #: W 10600245
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring ORecovery II
❑Aquifer Recharge
El Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
4. Date Well(s) Completed:
5. Well Location:
Smith No. 2
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
El Subsidence Control
❑Tracer
❑ Other (explain under #21
10/18/2023 AS-1
NCDEQ Incident No. 15454
Facility/Owner Name Facility ID# (if applicable)
1007 South Clinton Ave, Dunn
Physical Address, City, and Zip
Harnett
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.299143 N 78.614989 W
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ❑No
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.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one farm.
9. Total well depth below land surface: 20 (ft.)
For multiple wells list all depths ifdierent (example- 3@200' and 2@100')
10. Static water level below top of casing: approX 5
If water level is above casing, use
11. Borehole diameter: 4.5 (in.)
12. Well construction method: Auger,DP
(i.e. auger, rotary, cable, direct push, etc.)
For Internal Use ONLY:
14. WATE t ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft
15. OCi I ER CAS`tl for
mrilti rMrtd wellsa OR 1 fNER if licalll
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
I ft.
in.
14. INNER
CASING OR TUBING freorhermal dowd-loop)
FROM
TO DIAMETER
THICKNESS
MATERIAL
0 ft-
15 ft- 2 'a•
Sch 40
PVC
&
I It. in.
17. SCRERN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS MATERIAL
15 ft•
20 ft
2 in.
SCh40 PVC
ft.
ft.
in.
�.010
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
12 ft.
cement grout
tremmie
12 ft•
14 ft.
bentonite
prepack
ft.
ft.
19. SAN111
DEL PAC
If a Rcablr
FROM
TO
MATERIAL
No2 Sand
EMPLACEMENT METHOD
14 1"
20 ft-
prepack
ft.
ft.
20. DRILL NG LOG attach #ddltional sheets ifnecera
FRO!LI
TO
DESCRiP110N (color, hardness, soillrock 7� e, gr:dn size, etc.l
0 ft
20 ft
Orange silty Clay over tan-brn silty Sand
ft.
ft
ft.
ft.
ft.
ft.
ft.
ft
ft.
ft.
&
ft.
21. RENLARKS
Air-Sparge Well
22. Certification: 9„ nre upper
D72 Lawrence Oppee o=aegional
Lawrence Opp proh, $eNiCe�Oe 11/6/2023
ematklarry�regionalpmhing.ca mU5
Signature of Certified Well Contractor Date
By signing this form, I hereby certify 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
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
24. Submittal Instructions:
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.) Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Inaection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
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 Suplll% & 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