GW1-2021-02163_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 FROM TO DESCRIPTION
Well Contractor Name t 12 ft• 15 ft• Orange medium sand
3270 A ft. ft.
NC Well Contractor Certification Number I I L G 1 2021 js:;OII ER;I,ASING`tormt,Ih cl;sed velI OR,, N1 R if a lic file `, t
FROM TO DIAMETER THICKNESS I MATERIAL
Geological Resources, Inct„1.orn;ation processing Unit ft. ff. in.
Company Name UVVI C)Uctioll 16 INNER;GASING 0A1r BING_°eofher`mallclosedaloo"
WM-061175 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 ft. 2„ ' '"' sch 40 PVC
List all applicable well permits(i.e.County,Stale, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): Q VIZSGREEN,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 15 ft• 2 1°' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irrigation 0 ft' 3 ft- Grout Pour
Non-Water Supply Well:
3 ft. 4 e. Bentonite Pour
©Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19:'SA)vWA A'Mi)VPACh rU 7icab'le
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
4 ft• 15 ft• Sand Pour
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20:D12ILLING)L(<1Galtacti aBiliiional.sheets if-necssa`-`. >,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.5 tt. Asphalt
05/25/2021 MW-12 0.5 ft. 2 ft. Gray fine sand
4.Date Well(s)Completed: Well ID# 2 ft. 10 ft. Gray/brown clay
5a.Well Location: 10 ft• 12 ft• Brown clay
Gra Creek Su tte 0-000036605
ys ree pere 12 ft• 15 ft• Orange medium sand
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
6353 NC Highway 87, Fayetteville, NC ft. ft.
Physical Address,City,and Zip 21;RE117AR1ZS
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 IaUlong is sufficient)
34.90112 N 78.852486 W `4 ` 06/09/2021
Signature of Certified Well Contractor! Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(v)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 JA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or FINo 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 921 remarks section or on the hack 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 ifdifferent(example-3 c@t 200'and 2 a 100') construction to the following:
l
10.Static water level below top of casing: 10.40 (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: 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 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
13a.Yield(gpm) Method of test:
24c.For Water Supply&In.jection;Wells:Also submit one copy of this fo i rm 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