GW1-2021-00538_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Justin Radford 14.WATER ZONES
FROM To DESCRIPTION
Well Contractor Name 10.40 ft• 20 ft orange/brown silty medium sand
G R I ft. ft..
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER,if.ii"flcable
3270 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name FROM TO DIAMETER 16.INNER CASING OR;TUBING geothermal clo3ed-loo
2.Well Construction Permit#:NA ER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 ft. 5 ft. 2 in. Soh 40 PVC
3.Well Use(check well use): ft. ft. I
in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 1I Municipal/Public 5 ft. 20 ft. 2 1 ' 0.01 Sch 40 PVC
Geothermal(Heating/Cooling Supply) [3 Residential Water Supply(single) g g in,
hldustrial/COMMerCial [3 Residential Water Supply(shared)
18.GROUT
I
rrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
n-Water Supply Well: 0 ft' 3 ft. Grout Pour
Monitoring [I Recovery 3 ft. 4 ft. Bentonite Pour
ection Well:
quifer Recharge 1I Groundwater Remediation19.SANDIGRAVELPACK ifs Iic`ablequifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DJ Stormwater Drainage 4 20 t #2 Sand Pour
xperimental Technology Subsidence Controleothermal(Closed Loop) Tracer 20.DRILLING;)~OG tattaoh additional sheets'1ifnecessa . 4,.(Heating/Cooling Return) 130ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soillrock type,grain size etc.
0 ft• 20 ft• oran' a/brown silty medium sand
4.Date Well(s)Completed: 11/08/2021 well ID#MW-3 ft. ft.
5a.Well Location:
401 Express Shop 0-00-0000026075
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4302 Fayetteville Road, Raeford, NC 28376 ft. ft.
Physical Address,City,and Zip ft. ft.
Hoke 6944500001006 21.REMARKS
County Parcel Identification No.(PIN) '
o
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D
(ifwell field,one latflong is sufficient) 22.Certification:
35.0062523 N 79.17826030 W ��aF ,� T 021
6.Is(are)the well(s)OPermanent or 13Temporary Signature of Certified WeIT Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or MNo with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: One(1) SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20 (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: 10.40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method Augers
Au9 above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fort 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 Environmental Quality-Division of Water Resources Revised 2-22-2016