GW1-2021-02158_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford P 1v.wnTERZONEs . ,
FROM TO DESCRIPTION
Well Contractor Name 8 f= 15 t= Orange medium sand
3270 A JUL u i 2021 f=• f
NC Well Contractor Certification Number 1 `OU:TER CASING_`for multi-'&sets Hells OWCINER°if
GeoloGeological Resources
inforrrAm processing M TO DIAMETER THICKNESS MATERIAL
9 Inc. QVVR Section ft. ft. m.
Company Name 16..INNER`CASINGO1tUBING=e6ihermilcl6se8-lob'
WM-061175 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 R. 5 ft. 2" i" sch 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use):
17:SCREENa. , ts<r
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft' 15 f= 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) tt. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) L8`-GROUT ... <.,, ,. `
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 3 ft, Grout; pour
Non-Water Supply Well:
OMonitoring ❑Recovery 3 f= 4 f= bentonite pour
Injection Well: ft. fa
❑Aquifer Recharge ❑Groundwater Remediation =19.cSAND/GRApE1 PACKi tf a "]ic`able
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
El Aquifer Test ❑Stormwater Drainage
4
❑Experimental Technology ❑Subsidence Control
tt. 15 iSand
ft.
ZO.DRILLINC�tiOG,attach:a8ilitiolialslieets)if,necessa' }
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soill o k type,Tnin size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tt. 2 ft. Gray fine sand
4.Date Well(s)Completed: Well ID#
05/24/2021 MW-7 2 ft. 8 f= Orange/gray sand clay
8 tt. 15 ft. Orange medium sand
5a.Well Location:
Gray's Creek Superette 0-000036605 f ft•
Facility/Owner Name Facility ID#(if applicable) ft. ft.
6353 NC Highway 87, Fayetteville, NC
Physical Address,City,and Zip21 REDIARKS � �„
Cumberland 0441-48-2904
County Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
34.90112 N 78.852486 W 06/09/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary 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: ❑Yes or END copy of this record has been provided to the well owner.
Iftlus is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back ofthis fonn. 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-wafer supply wells ONLY with the saute construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 15 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 10.69 (ft) Division of Water Resources,Information Processing Unit,
ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 611 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
6" Steel Fli ht Au er 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: g g 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
24c.For Water Supply&Injectio
n 13a.Yield(gpm) Method of test: n;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-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013