GW1-2022-05410_Well Construction - GW1_20220311

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
VINCE FEDERLE 14.WATER ZONES .
Well Contractor Name FROM ft. TO DESCRIPTION
ft.
A - 3552
ft. ft. i
NC Well Contractor Certification Number 15.OUTER CASING for mutt*-casedfweils OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
rt. ft. i in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable irell construction permits(i.e.UIC,County,Stare,variance,etc.) 0.0 ft- 24.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): B. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 24.0 ft' 34.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. fr. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 20.0 ft. PORTLANDBENTONITE SLURRY
(EMonitoring ORecovery ft. fr.
Injection Well:
ft. ft.
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage 22.0 ft. 34.0 fL 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilkock type,gmin sim,etc.
0.0 ft. 1.0 ft- TOPSOIL
4.Date Well(s)Completed: 10/22/21 well ID# MW-16 1.0 ft- 34.0 ft- TAN CLAYEY SANDY SILT
Sa.Well Location:
rt. ft.
CROWN FORD ft. ft. MAR I
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. _
256 SWAIN STREET FAYETTEVILLE 28303 fr. ft.
Physical Address,City,and Zip ft. ft.
CUMBERLAND 21.REMARKS
County Parcel Identification No.(PIN) BENTONUE SEAL-20.0-22.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
350 05' 02.67" N 780 57' 01.25" W �,,,�,,� �? _
10/29/21
6.Is(are)the well(s): INPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)eras(ivere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If ilus is a repair,fill out known me11 construction information and explain the nature of the of this record has been provided to the well owner.
repair tinder 921 remarks section or on the back of this forty.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 34.0 (ft.)
For multiple trells list all depths ifd#jerent(example-3 a 200'and 2@100') Submit this GW-I within 30 days of well completion per the following:
10.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/Jlrater level is above casing,use
11.Borehole diameter: 8.0 (in.) 24b. For Infection Wells:Copy tobWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY:
24d. For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018