GW1-2021-02160_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 q. T ,14, ITERzO;'Es„
® FROM TO DESCRIPTION
Well Contractor Name 8 ft. 115 ft' Orange medium sand
3270 A MA ft. ft
NC Well Contractor Certification Number CStC1�UnIZ ,t5 OU7 ER,CxfNG,for moth caseilwells:012 LINER;ifa licatile; °,
�tittJ�Fir��eion FROM ft• TO ft• DIAMETER'" THICKNESS MATERIAL
Geological Resources, Inc. 8 D1fyRsec
Company Name r 6:NNER;CAS11)TG..OR'XVBIN 6 e61herma1 closed=lob"
WM-061175 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft. 2" i" SCh 40 PVC
List all applicable well pennits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 15 ft• 2 '"' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) ft. ft. i�•
18 GROTTT
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 3 ft- Grout' Pour
Non-Water Supply Well:
eMonitoring ❑Recovery 3 ft. 4 ft. Bentonite Pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19=SAN_D/GRAVELI'AG 11f ppii able
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 ft. 15 ff' Sand
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control „, ,
20413RIUL7NG)u` G,attac had'di wnf s6eefstif 6ecessa_;"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft- 0.5 ft. Asphalt
05/25/2021 MW-11 0.5 ft. 4 ft. Gray fine sand
4.Date Well(s)Completed: Well ID#
4 rt. 8 ft. Gray clay
5a.Well Location:
Gray's Creek Superette 0-000036605 8 ft. 15 rt. Orange medium sand
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
6353 NC Highway 87, Fayetteville, NC ft. ft.
Physical Address,City,and Zipx21
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 a;/ 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 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FIND 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 i121 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: 15 (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: 10.20 (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 Steel 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&Iniection Wells:i
p
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