GW1--05504_Well Construction - GW1_20240912

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14..WATER ZONES , •
Lawrence D. Opper FROM TO DESCRIPTION f
Well Contractor Name ft. ft.
NC3322-A ft. ft. 1 i
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licablel
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. 2 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
❑Agricultural ❑Municipal/Public 2 ft. 12 ft. 2 1n .010 sch40 PVC
ft, ft. in.
El Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM9S.GROUT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 1 ft. Cement pour
Non-Water Supply Well:
OMonitoring ID Recovery 1 ft. 1.5 ft• #20 Bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ID Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
1.5 ft- 12 ft #2 sand prepack/pour
❑Aquifer Test ❑Stormwater Drainage
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) ID Other(explain under#21 Remarks) 0 ft. 1 ft. crushed stone
4.Date Well(s)Completed:
7/26/2024 MW-1 1 ft• 12 ft• clayey silt
ft. ft.
5.Well Location: ft. ft.
Cencomp, Inc ft. ft. t',
Facility/Owner Name Facility ID#(if applicable) ft. ft. •:::/47..,..'7748 US Bus Hwy 70, Clayton ft. ft. i1[ Y 2
Physical Address,City,and Zip 21.REMARKS Ir
Johnston :.. �
cGt,c : .;,,t.: , •
County Parcel Identification No.(PIN) dr l v
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:' 1
(if well field,one lat/long is sufficient)
35.6095236 N 78.415445 Lawrence Opp ==�Mo-o�
e. �; - 8n/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
with 1SA 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 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 ofthisform. 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: 12 (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: 2 (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
above, also submit a copy of this!form within 30 days of completion of well
12.Well construction method: Geoprobe DP 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 to the county health department of the county
where constructed. I 1
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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