GW1-2022-01831_Well Construction - GW1_20220210

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ronald barron ,.11 ,warERn©rrEs ._-�._, ._ r
Well Contractor Name FROM TO TDESCRIPTION
2091-A
ft. ft. '
NC Well Contractor Certification Number r s v „_
i 15:(O"l17 ERiCASING for#aaiti-asedswdb ORiLINER"'if ii` `Me
Piedmont Industrial Services .FROM TO DIAMETER THICKNESS MATERIAL
in.
Company Name rFR0fM­NER,CA SINGUR TUBING4-""the`i'iil'lcloxd=lbu2.Well Construction Permit#:N/ATER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) t.' 5 ft- ,2 m• s h 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well:. 173SCREEN 3 ;;'
FROM TO I DIAMETER SLOT SIZE THICKNESS 1 MATERIAL,
Agricultural DMunicipal/Public 5 ft. 15 ft 3 i"• .o1D Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft ft in.
Industrial/Commercial DResidential Water Supply(shared)
In,i tion FROM TO i MATERIAL EMPLACEMENT METHOD&AMOUNT
Non=Water Supply Well: ft. 2 ft. Concrete Poured
x Monitoring Recovery 3 ft- , 3.5 rt. 318 sent:chips Poured
'Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19[SAIVD/GR9VEMPAGK; fci It file;
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 3.5 ft- 15 ft- Finer sand Tct3friie
Experimental Technology DSubsidence Control
i
Geothermal(Closed Loop) DTracer :,IWDRIDWNG11OG'a'&c'h9dditionals
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO 2 DES
0 ft- ' hardness,soiUrock e, rain size,etc.. ft. Top soil,oil w/tariftlack sands
DESCRIPTION(color,
4.Date Well(s)Completed:1-27-22 Well ID#MP4 2 ft. , 5 ft. Oran- a sandy day
Sa.Well Location: 5 ft IS f`' ; dark soil w/waste
City of Fayetteville N/A ft ft. ; Sir @ a5
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
400 Milan ;Road Fayetteville, 28301
Physical Address,City,and Zip
Cumberland N/A ':10REMAR>Wo
t > r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
35.07457769 -7886209391
N W ^nrC Ltf11G-3-22
6.Is(are)the well(s) x Permanent or 'DTemporary Signature of Certified Well Coiitractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or .XDNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this 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 owner.
repair under 921 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-I is needed. Indicate TOTAL NUM$ER of wells construction details. You may also'attach additional pages if necessary.
drilled:N/A SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:Methane Detection (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:$ (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: 9 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
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13a.Yield(gpm) Method of test: 24c.For Water SuoDly&Iniecti+on 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.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22-2016
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