GW1-2022-01708_Well Construction - GW1_20220131

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Sam Bowers 14.,WATER ZONES L_j
FROM TO DESCRIPTION
,ON
Well Contractor Name ft. ft.
3220 A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(fdr mdlti-cased wells)OR L ftloll�
TM=R
FROM TO DIAMETER
Geological Resources, Inc. ft. ft. I in.
Company Name 16.INNER CASING OR TUBING eother id,tIosed40_db)',',
WM 0601188 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
List all applicable well permits(i.e.County,State,Variance,Injection,etc) 0 ft' 2 ft- 2 sch 40 PVC
ft. ft. in.
3.Well Use(check well use): -
17.SCREEN-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural OMunicipaMblic 2 ft- 12 ft' 2 in. 0.010 sch 40 PVC
OGeothermal(Heating/Cooling Supply) ❑OResidential Water Supply(single) ft. ft. in.
0 Industrial/Commercial. OResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DhTigation 0 't' 0.5 ft- Grout Pour
Non-Water Supply Well: 0.5 ft- 1.5 ft- Bentonite Pour
IDMonitoring DRecovery
Injection Well: ft. ft.
OAquifer Recharge oGroundwater Remediation 19.SAND/GRAVEL PACK"if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Storage and Recovery OSalinity Barrier 1.5 ft- 12 ft. Sand Pour
OAquifer Test OStormwater Drainage ft. ft.
0 Experimental Technology DSubsidence Control 20.DRILLINGI LOG attach additional sheets ffritcessiiiy)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,soil/rock in sl etc.)
0 Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0 ft 5 ft. Dark gray medium sand
4.Date Well(s)Completed: 12/14/21well ID#M W_1 5 ft 12 ft. Gray/brown medium sand
ft ft
5a.Well Location:
McMillan-Shuler Oil Co. 00-0-0000011258 ft ft.
Facility/Owner Name Facility D:)#(if applicable)
708 Winslow Street, Fayetteville NC 28306 ft. tt. JAN 31 202?
Physical Address,City,and Zip 21.-REMARKS
Cumberland 0437-20-5297
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lattlong is sufficient)
35.041776 N78.89016 W 12/17/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or OTemporary 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: OYes or E)No 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. SUBMITTAL INSTUCTIONS,
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: 3.15 (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 ONLY: 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: 6" Solid flight auger construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
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:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 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 Resources Revised August 2013
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