GW1--04033_Well Construction - GW1_20240708

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 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 ltcable)
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. 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
ID 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
El Irrigation 0 ft. 3 ft' Cement pour
Non-Water Supply Well:
3 ft. 4 ft. #20 Bentonite pour
EiMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERL\L EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 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,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 15 ft. Silty Sand
ft. ft.
4.Date Well(s)Completed: 5/23/2024 MW-1,MW-2,MW-3
ft. ft. _ ... ,/
5.Well Location: ft. ft. L.Le L_i \/ E L)
Speedway 6994 ft. ft. I�II 4
Facility/Owner Name Facility 1Db(if applicable)
'"I 0 8 2�Z
ft. ft.
5030 Yadkin Road, Fayetteville ft. ft. lfta:n'..vt•a 3-r:r.vwn„1 Unit
Physical Address.City,and Zip .Q ti It 3C<$
2t.REMARKS
Cumberland
County Parcel Identification No.(PIN)
/ I5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:/
(if well field,one lat/long is sufficient)
35.0835622 N 78.9683502 W Lawrence Oppe .� m 6/3/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary 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
7.Is this a repair to an existing well: ❑Yes or FlNo 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 f different(example-3@200'and 2@I00') 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: 3'75 (in.) 24b. For Injection 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
Geoprobe DP
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-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013