GW1-2022-07655_Well Construction - GW1_20220818

WELL CONS`l'R'UCI-ION RECORD For lrtcrantl Use ONLY:
This Earn can be used forsinPk or rmihiplc+ycils
1.Well C tractor Information:
;tJ:N`ATLR 7.Aitii:S
Rich Lemire FROM TO I DFSCRiPt1ON
AVeitGnnicraotl,a(rK
2593A i Tai�.@,,o1 D A. f1.
NC1Ve11 Compactor CeniftcationNumber 15.',QUTF.RCASING fnr'iii'l114iirada`tns ORL1NKR it'e ikabk
AUG2Q2� FROM To DIVASETPR TuICK'NF'" 11ATERIAL
SAEDACCO Inc 0 it. 5 ft. 2" in. SCE-40 PVC
l ofigr;url Urrl 2b imm CASING OR-7 UBING t entbermal elnseddor►pj
D?/QlB0G 11011 TO DLA�IFTF.R. T111cwxFSS MATTRIAL
2.Well Comltfvetion Permit#: n. ft. .
Ivry all aprahcudle wrdf pr,mfts fi-c.Cpirnh St;'ftr.1'ariu rcc.7ryCt0Ari ri
n.
3.Well Use(Check well use): 17:fiC'Rti l n : "-•
Water Suppky,Well: FROM I TO DtArtfl.T1;R SI.OT:+`12E 7111001NP4 MATPRIAI:
1�1r1glieuhpra! omunicipaMublic 5 ft. 15 ft. 2" in; .010 SCH-40 PVC
OGeothemtal(HeatinprCooling Supply) 131tesidential\later Supph'(single) ft. tt. in.
pindustriiKontmcrciA 011csidrntial Water SupphF(shred) ']BrGROIIT
FROM TO MATF;ttmt PAIPIACrMLNT\icoo R AMOUNT
Dim ytion 0 ft. 2 (1 PORTLAND POURED
Non-Water Supply Well:
6Monitoring QRaDt ct)
injection Well: ft. ft.
0AquiferRcch,'irge 06roundmatcrRemcdiation 19.SANDiGRA'z9LI'ACK4it alittliciiii1i
FROM to I MATrRIAI, PMPI A(Yy1P\T:N/TiloD
❑Aiimifer$torogc and Rccosrn' ❑Salinity Hirr cr 3 ft. is ft, SAND #2
OAgnifcrTcst OStormwatcr Drainage
DE>,perimcntal Technology 0Stlbsidcncc Control
'20i`DR11 ANG'LOG 7anach':additionat''sbrels iftiit man`,'>
oCko111ernu l(Closed Loop) 07tacet ,FROM TO DFSfRIPttON fwbr.hnrdnrii Y.Wnwk ivori won ifrr.t/c:
❑Groille1n1a1(1{eadn 1Goolitte Retutn) OOtlter tex lain under 0)1 Remarks) 0 ft. 5 n. GRAY SILTY SAND
5 ft. 15 ft. REDISH SILTY SAND
4.Date Well(s)Completed: 7-28-22 Well ID#riw-a
n. rL
S&L Well Locathm: ft. ft.
CIRCLE K #2723027 n. ft.
Faclitr/Owncr Nan+e Facility IDk(if appli able) fl. ft.
2001 Skibo Rd., FAYETTEVILLE, NC, 28314 ft. ft.
Physical Address City.and Zip 3L-Ri MARK5'-
CUMBERLAND Bentonite seal from 2-3'
Cotrul)• farces ld:rd ricalionNo,(PIN)
5b.iA%titude and Longitude in degmcs/mini tcslseconds or decimal degrees: 22.Certification:
Cif+ycll rum,Qre I:W"Iprfg,ir:sftlliewut) 7
N W X_tirr / v`„C/ Q/fMwt�..2 .M:_ Y•r 7/28/2022,..,_--
Signat ofCcniN'J,'dl Contractor Daic
6.IS(are)the well(s): MPerinanent or 131femporary fh-signing this f rm,I herrbT certify thm Me+nrllfs!sms favor)eonrlturietl ht&r czrrldnee
+rGR I SA rVCAC 0.?C.f1/(lt?ar 1 id A'CAC o'C;!12A�tut•!!G`r�asn3r,:ricui cr<rri<iirrtfa tr+t�t fJnre<r
7.Is tbis a repair ft)an cai:fting well: f7Ves (or 18iN(► t'tl,i of this rev mW laar hren pnjrid.d ro 7h,+ryll rnpnFr,
If this;Ee a wpair,fill pot koohet ryrll ea,rstt)nvta»Infoomadtnr and ral,lahr dw,tarere of rbr
retwir tioder 021 n+narks xerfimr rir nn dir hank of drlx for,n. 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 co►utrucied: 1 consttuc►ion details: You pales if navessary.
For,naldpde irttecth n at nivi-warer smpp?dy reelds ON11'wirlr ihr,same construction.you Cent
tal,nurc9nr�rrrn. SUBMITTAL WSIUCTIONC
9.Total well depth below land surface: 15 (ft.) 24a. For all Wells:. Submit this form Avilhin'30 days of completion of well
For,ntdliple Kell+lfrtafl depths ffdditi•rent ieamud;(e-30200'aW 20,1001 construction to the following:
10.Static water level below top of casing: 8 (Iy,) Division of Water Resburres,Information Pr cessing Unit,
If uvnee level 0 id-ot�e oaing,ete•",^ 1617 Mail Service Center,Raleigh,VC 27690-1617
11.Borehole diameter.8.2 5" (in,) 24b.Egr IllJMjJjtEt WSIj4 ONLI In addition to sending the form to the address in
24a above. also submit a copy of this form within'A days of completion of Dull
12.1Yell Congruction method: AUGERS construction to the followiue;
Re-stir.r-redwy.cable.ditm push ctc-)
Division of Water Rcsaun'cS;Iindcrground.Injection Control Pmgrany
FOR WATER SUPPLY q'ELLS ONLY: 1636 Alall Service Center.Raleigh,NC 27699-1636
i
136 Yic1d(la►m) Nct11IId of test Zdc.For Water Supply&injection Wells:
- Also submit one cop)' of this farm 1i-4bin :O days ofcontplet ion of
13b.Uirinf�YKinn h' - Amount: - well consiniction to the counh' h6alth dcpannicnt of the cmmt�•whcre
type: - Constructed, �
Faun Gt1r-t Nonli Catol'una Dgpsnmetu of Enr toaa►:rn and Natrtral Reularces-Uivislon of 1Vatci Rr soots Revised AVSUSt'2013