GW1-2021-02159_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 94-_VATER;zONES
FROM TO DESCRIPTION
Well Contractor Name ��C
3270 A 8 ft. 15 ft. Orange medium sand
`1 �� 1 Z�2� IS:,OUTER°CASING' .nulh caselgwells;OR`LINER;f;a licatilii v � i
NC Well Contractor Certification Number JUL
Unit FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. pFct;essing ft. it. in.
n I l6 INNER CA`SING<OR TUBING "feohermal;closeil=too
Company Name tiR cJ��
WM-0611 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft' 5 rL 2" in. sch 40 PVC
List all applicable well permits(i.e.County,State, i/ariance,Injection,etc)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft' 15 ft• 2 'n' 0010 sch 40 PVC
❑Geothennal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT __
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 3 rt. Grout Pour
Non-Water Supply Well:
OMonitoring ❑Recovery 3 f[. 4 rt. Bentonite Pour
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEUI'AC-K(if a liegble)t-vf ' � a
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 ft. 15 tt. Sand pour
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
5'-'20:`DRILLING'tiOG attach additional sheet`saif:hecess5 A" ,.w. � °3
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soir/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 e. i[. Gray fine sand
4.Date Well(s)Completed: 05/24/2021 Well ID#MW-8 2 r[. 8 t[. Orange/gray sand clay
8 ft 15 ft. Orange medium sand
5a.Well Location:
Gray's Creek Superette 0-000036605
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
6353 NC Highway 87, Fayetteville, NC
Physical Address,City,and Zip
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 tat/long is sufficient)
34.90112 N 78.852486 W `0/°7 06/09/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 21'ermanent or ❑Temporary By signing this form,I hereby certify that the we//(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 FIND copy ofthis 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 ofthis 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: construction details. You may also attach additional pages if necessary.
For nuthiple injection or non-water 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 ifdifferent(example-3@200'and 2 n 100') construction to the following:
10.Static water level below top of casing: 10.24 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
n
11.Borehole diameter: 6 (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
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