GW1-2021-02164_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information: qqq+ f
Virgil Wilson p9l 14.WATER ZONES
y ���ddd FROM TO DESCRIPTION
Well Contractor Name 7 ft. 20 ft. Wet
4473 JUL L 2021 ft. ft.
NC Well Contractor Certification Number g Unfit 15.OUTER CASING formulti-cased lwells OR L1NER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. Inform a�i�n,6�Sec Section ft. ft. in.
Compam Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 ft. 2 in. sch40 PVC
List all applicable irel/permils(i.e.County,State, Variance.Injection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 It' 20 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPPIY(single) ft ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 5 ft. 2 ft- Portland Cem Tremie
Non-Water Supply Well:
2 ft. 8 ft- Bentonite Chi Tremie
hJMonitorine ❑Recovero
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
f`
❑Aquifer Test ❑Stormwacer Drainage 8 f`• 20 #1 Sand Trernie
ft. ft.
❑Experimental Technology ❑Subsidence Control
20,DRILLING LOG attach addifiotiai sheets if necessa.
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 6-1 8-21 Well ID# MW-01
ft. ft.
5a.Well Location: ft. ft.
Hertz Corporation ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
101 Airport Road, Fayetteville, North Carolina ft. ft.
Physical Address,City,and Zip
21.REMARKS
Cumberland 0435054007000 8°FMC
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer'fication:
(if well field,one lat/long is sufficient)
35.000671 N -78.898900 N !e 6/24/21
Signature of CeibffflTWell Contractor Date
6.Is(are)the well(s): IZPermanent or ❑Temporary 13v,signing this form, 1 hereby cerli(v that the srefl(s)uas(here)constructed in accordance
Wait 15A NC'AC 02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and dial a
7.Is this a repair to an existing well: ❑Yes or ElNo copy qI this record has been provided to the cell owner.
4 this is a repair/ill out known well construction information and explain the nature o(the
repair under 21 remarks section or on the back o/'this 1brrrt. 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-Crater supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 24a. For All Wells: Submit this form within 30 days of completion of well
hor multiple treffs list all depths if dillerent(example-3 c@200'and 2 ct 100') construction to the following:
10.Static water level below top of casing: 7 Division of Water Resources,Information Processing Unit,
1/'o-aler level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Injection Wells ONLY:�In addition to sending the form to the address in
8 1/4 HSA 24aabove, also submit a copy of'this form within 30 days of completion of well
12.Well construction method: 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
m 13a.Yield
(gP ) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within'30 days of completion of
I3b.Disinfection type: Amount well construction to the county health department of the county where
constructed.
I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013