GW1-2022-01827_Well Construction - GW1_20220210

WELL CONSTRUCTION RECORD (GW-1) ['For Internal Use Only:
1.Well Contractor Information:
Ronald barron ,,�JtXWATERIZpNESZ ,
Well Contractor Name ..FROM ...TO
i DESCRIPTION - - -
2091-A
ft. `. ft. 4
NC Well Contractor Certification Number p1S ZUUTER CASING+fe��rlti t`ared�we9s:ORillll!t$Rf fttt We,�
Piedmont Industrial Services FROM TO DIAMETER THICKNESS MATERIAL
ft. ft m
Company Name �i 11NNER?GASING OR}TUBING "'lYefeil.elmca=lad
2.Well Construction Permit#:N/A FROM TO. DIAMETER '. .THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc.) �+3 ft. 1;Q ft. 2 1O' f SCh 40 PVC
3.Well Use(check well use):
ft. ft.` in. .
Water Supply Well: 11r7:4SCREEN.... 'w �..�Z _..." .� _, F •.
FROM TO DIAMETER SLOT SIZE TM
CKNESS MATERIAL
Agricultural E3Municipal/Public 1'0 ft 2'S ft. 2 '" 01'0 Sala 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. '` i 6
Industrial/Commercial .Residential Water Supply(shared) .�10�GROUT..,_._[ t ,,
Irri ion r FROM %,TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. s ft- Concrete Poured
x Monitoring Recovery S ft. , .8 ft. 318.gent.t QS: Poured;Injection Well:
Aquifer Recharge .Groundwater Remediation
21�$S'iRND/GRA VELNWC ifca "lik
Aquifer Storage and Recovery Salinity Barrier FROM TO, MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage .8 ft- 25 ft. Filter sand . Tremie
Experimental Technology .Subsidence Control
Geothermal(Closed Loop) f3Tracer :�lOi,DRII Lr1NGLOG"a'tta`eYlidditioalf"`sheebiif_neeessi-:: _-. ,_ x
FROM TO DESCRIPTION color,hardness,soil/rock type, ram size,etc.
Geothermal Heating/Cooling Return) . Other(explain under#21 Remarks) 0 ft. ; .2 ft.'.Top 50'1
4.Date Well(s)Completed.1-26-22 Well ID#MW-4 2 ft. 5 ft. `: Tan Orange sand' Clay
5a.Well Location: 5 ft. �' ft- ' dark Soil wtwaste
City of-Fayetteville N/A 15 ft• 25 ft• .gray Gay
Facility/Owner Name Facility ID#(if applicable) ft. ft. ST @ 25
400 Milan Road Fayetteville, 28301
Physical Address,City,and Zip ft ft.
Cumberland N/A
County Parcel Identification No.(PIN) and
4"well
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: f
35 07229683 N -78.8633591 W
—�•r.�•P���� 2-3-22
6.Is(are)the well(s) X Permanent or=Temporary Signature of Certified Well Contractor ��D
By signing this form,I hereby certify that the 1-a (3vgre)icon{strucled In accordance
7.Is this a repair to an existing well: '.DYes or XINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 �1 Corlstruction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well own tE 1 0 2027
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 Welisltaving the same You may use the back of this page to provide a(%J,0 !Wi:Ijilite details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attaeyhittoft2fipges,lf>ses �ry',l
drilled:`M/A SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(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:8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction methodAu er above, also submit one copy of this form within 30 days of completion of well
9
(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
i
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 form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i