GW1--02593_Well Construction - GW1_20240426

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. Opper 14.WATER ZONESFROM TO DESCRIPTION L L
Well Contractor Name ft. ft.
NC3322-A ft. ft.
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.
•
Company Name 16 INNER CASING OR TUBING(geothermal closed-loop),'� s_
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 6 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): l7.'SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 6 ft• 16 fa 2 in' .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '48.GROUT-` '' F . " '� `
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 2 ft• cement grout pour
Non-Water Supply Well:
❑Monitoring ORecovery 2 ft. 4 ft• bentonite prepack/pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19,SAND/GRAVEL PACK(if applicable)'' •`' •'" - " `"
FROM TO MATERIAL EMPLACEMENT METHOD
❑A uifer Storage and Recovery Salinity❑ Barrier
4 ft• 16 ft• No.2 Sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets ifneces"sary) -
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) 0 ft. 7 ft• Red-brown, moist,med stiff slit and clay
3/13/2024 MW-1 7 ft. 9 ft. Tan,.moist, med dense f-c sand,tr silt,tr clay
4.Date Well(s)Completed: ft. ft.
9 10 white,grey wet med dense clay,tr silt
5.Well Location: ft• 16 ft' Formation,refusal
Eastern Blvd.Family Fare BP#220 ft. ft. rt„:,:„..,( •-" • „
_,
i l .l'-
Facility/Owner Name Facility ID#(if applicable) ft. ft.
201 S. Eastern Blvd. Fayetteville ft. ft,
Physical Address,City,and Zip -21.REMARKS.b'•r ,, - 4'0;r,-.-t,,rZ;?r ..,.r•R... :,,,:>
Cumberland D't`aco:3L," 'a s',..Y
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(ifwellgsufficient)field,one lat/lon is pally signed wren.Opper
DM cn-Lawrence Opper,ssaegional
35.0452090 78.865347 Lawrence Opper:'emakIe;ry@eg;an;lproeln9<on,,mD5 3/27/2024
N W a.t,.2o».o2.oto9»52 os•oo•
Signature of Certified Well'Contractor Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,1 hereby certiP 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 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: 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: 16 (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:
10.Static water level below top of casing: approx 9 (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: 3.25 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Geo robe above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: p 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
24c.For Water Supply&Geothermal Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: 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