GW1--01349_Well Construction - GW1_20240304

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. Opper FRWATER ZONEs . -v :
DESCRIPTION
Well Contractor Name ft. ft.
NC3322-A ft. • ft.
NC Well Contractor Certification Number ;I5.-OUTER'CASING(for multi-cased wells)OR LINER(if sip licable)
FROM TO DIAMETER ' THICKNESS MATERIAL
Regional Probing Services ft. ft. ; in.
Company Name 16.INNER CASING OR TUBING'((eothermal closed-loop).:''
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 28 ft. 2 , 1n' 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): 17.SCREEN - ":.: . .
Water Supply Well: FROM TO DIAMETER : SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 28 it 48 f`' 2 1°' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply ft ft. in.
( S/ g PP Y) PP Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) :IS•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 f`• 5 ft. cement grout pour
Non-Water Supply Well:
RIMonitoring ❑Recovery 5 f` 26 fL bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK(if applicable)-"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
26
❑Aquifer Test ❑Stormwater Drainage f`' 48 f`• #2 sand prepack fltr/pour
ft. • ft.
❑Experimental Technology ❑Subsidence Control
M.DRILLING LOG(attach additional theet if necessary) '= °= ,.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) ,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 f`• 48 ft. Silty Clay over Silty Sand
2/8/2024 MW-7 ft. ft.
4.Date Well(s)Completed: ft. ft.
5.Well Location: ft. ft. �� -• J '.... "�s/F-
Speedway 6993 ft. ft. V ! t _"
Facility/Owner Name Facility ID#(if applicable) 4 2UL ft. ft. MAN {0 ti'
670 N. Reilly Road, Fayetteville ft. ft t,
Physical Address,City,and Zip 4'r/"'S:G Ichf)r�� .1 O t uF
21.REMARKS 't, ' ' "
Cumberland
County Parcel Identification No.(PIN) _
`
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ' AAt
(if well field,one lat/long is sufficient) A tryeodtr,�w,eo�eo
34.099706 N 79.011004 W Lawrence Opper p-0 �`"k" 2/28/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certity 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 IJNo 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: 48 (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@100') construction to the following:
Division of Water Quality,Information Processing Unit,
10.Static water level below top of casing: 40 (ft.)
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter 5 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Auger 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 t i 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