GW1--03480_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lawrence D. Opper FR.WATER ZONES
FROM TO DESCRIPTION
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 livable)
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. 3 ft. 2 in' sch 40 PVC
List all applicable well construction permits(Le.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 3 ft' 13 r`' 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) rt. ft. in. i
❑lndustrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMoi'.1
❑Irrigation 0 ft. ft
Non-Water Supply Well: 1 cement grout pour
OMonitoring ❑Recovery 1 ft. 2 ft- bentonite pour
Injection Well: ft. ft.
0 Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEM ENT METHOD
❑Aquifer Test ❑Stormwater Drainage 2 ft- 13 ft- #2 sand Prepack/pour
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 ft. Silty Sand
4.Date Well(s)Completed: 4/13/2024 MW-4 5 fi. 13 trt. S �`laY••' r<i
hi
5.Well Location: ft. ft.
Former Arnold's Corner Incident#42056 ft. ft. ' JUN 1 1 2G24
Facility/Owner Name Facility ID#(if applicable)
ft. ft. (llt6fliif4f 51 P'r✓ ` U!d!
407 NC Hwy 15/501 ft. ft. Dy;,.,-:31,2,
Physical Address,City,and Zip
21.REMARKS _
Moore
County Parcel Identification No.(PIN) , ,,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification.4
t
i agouyng dM a eDpp
(if well field,one lat/long is sufficient) •W . nce °Nin-'a^"14eO °
o-NegmalpradngSeM<es,.,
35.3777071 email-la,,y@regora,,prodng.can.
N 79.28898 N, Opper c-USDate 2021a5011231:159,1Y10 5/1/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA 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: 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: 13 (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@/00') construction to the following:
10.Static water level below top of casing: 4 (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 (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
136.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013