GW1-2022-07656_Well Construction - GW1_20220818

WELL CONSTRUCIJON RECORD For lracnuil Use ONIN:
This form can N,used for siark or trmltipk wells
1.well CAmtractor.Infornlation:
14.WATER ZONCS.
Rich Lemire FROM TO DFtiCRIPIIO's
Weil cortricint Native f1. fit•
2593A e D fl.
E D.
NC Well Comractor Certification Nun bcr 15.OUTER CA5fNG tar aiulti-cas d hells OR LiNER if'it lk0k
•t FROM TO D(AMETF.R� THICKNESS \1ATF..R1AL
AU 1
r S 2022 0 ft. 5 ff. 2 in. SCH 40 PVC
SAEDACCO Inc
('.tlllql:nn't\"SnIC +•• •- '1ti..INN[?RCA$INC"ORTUBING(eortxrrnalclirscd•fan.. . '
If)tt?fFliB.tOS1 ��Una FROMDVV TO OCA\(ETER T(IICA\ES3� MAITRIAL
2.well Construction Permit#: �� A. rt. �•
/r.rr all alldirahle well prnnitr fi,r.Counh•..SfMr.I briatrce,.4a't)bt eye.I fit. fl, in.
3.well We(check well use): 17 SC.REEN-
Water Supply Well: FROM TO D1AMt:TF;R $1.OTS(7E TfH(1(%FS% MATF.RIAl.
bAgricultural G1vlunicipaMblic 5 fit. 15 fI• 2" in. O10 SCH-40 PVC
OGeotlkmtal(IlealillptOOling Suppl)') I7Residential Wtiter Supph'(single) (I• fl.III.GROUT
„ ..
01ndustriaKonuncrcial h)Residential Water Supph•(shared) FROM TO d1ATFRIAt. I E\TPI.ACEMr:\T11tF.niODAAh1011\T
❑Iri ation 0 it. 2 ft. PORTLAND POURED
Non-Water Supply Well:
6dMonitoring ORccoecty
injection Well:
❑Aquifcr'Rccharge OGrouttdnatcrRcutcdiation 19.SANDiC.FROM TO t1ATi:R1RAVELI'ACK'(ir rltin At.
lMPLACI\/E�TNtTf10If
0AquiferStorrge and Recovery OSAnity Htirricr 3 fit. 15 fit. SAND #2
O Agnifcr Tcst O.Stormts�ftcr Drlinoge
OEs7lcrimcnhd Technology 08uhsidcnce Comrot
20:'DRiI,LING"LOG(attach additional s s if neccssan'
❑G.-oillennal(Closed Loop) OTracet iROM' TO DFSCR(P170\ttubr•bardneti,snrt'rtirktr 6Are.W.
OGeothentlal(•Ilcatio tlCooline Return) ❑Other 4ex lain under#21 Remarks) 0 ft. 5 ft. GRAY SILTY SAND
5 ft. 15 ft. REDISH SILTY SAND
4.Date Well(s)Completed: 7-28-22 WelliD#Mw-9 fl. ft.
Sa.Weil LAFeathm: ft. ft.
CIRCLE K #2723027 ft. A.
Faqir)•O+trcr Nana Facility ID#(if appiiAblc)
A. fit.
2001 Skibo Rd., FAYETTEVILLE, NC, 28314 ft. ft.
Physical Addrsk City,and Zip 2L R!MARt(Cr
CUMBERLAND Bentonite seal from 2-31
Gantth PAttel Id;raifrCttlt)tf NP.(Pl\)
511).1.I1titude and Longitude in degneslminutesAceonds or decimal dorm,: 22.Certification:
(if reell field,one liblotie is Stdlicinif)
�.
7f28/2022
Sigrlturc ofCcni _.4dI Co11 Cior Date
6.Lc(are)the well(s): -7Dpennancnt or OTemporary /�v yy4ni,rr this ft•nn,1 hereby rerfif.•that the.irll+si sivs ftwrr)i•onvin/cled in tweordanre
with!SA NC,tC 02C.0l(v)nr!SA NC/IC'(lyC:0217t/Il e'!1 Cmrtslrtn'lian fk�/ulnrtls and Hurl a
7.Lc this a repair to an existing Drell• 0Vvs or MNo gimpy of this reranl hnclwew pmr!Nd rr tM aril corner.
Iflh(.t is a relvik,fill M41[norm wril rot)-cmalan hrfnrvturrkui and explaM the wrure col(for
relmir tiorder 021 rr,nark%- %ertioe or rut the bark of this form. 23.Site dia);ram or additional well delails:
You may use tire.back of this page to provide:additional well site details or well
8.Number of wells constructed: 1 colsttction detaits. You tnav also attach additional palvs if oecessar)
Far'"aldple MJivrimn of at'vi- arer suplrly wells ON1.)'•wlrh(he same emnstrurtiom you Can
svbmirpnr fwnn. SUBMITIA •INSTUCTIONS
9.Total well depth below land surface. 15 (ft.) 29a. For All Wells:. Submit this.form within 3(1 daj's of completion of%veil
Ivor rnirhiple trells lira all delnhs(fdiftere/u frxmthle.:16.3fitl'azrrl 20 ifs)') construction to the fbltoning:
10.Static water level below top of casing: 8 (ft.) Division of Water Resou.mes,Information Pracessing Unit,
if itYttrr level is above crishtg.tom"." 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.8.25^ (in.) 24b.For flijalign WSQa ONLY In addition to sending the fort to live address in
24a above. also submit a copy of this form)viihin 30 days of completion of%e11
12:1Vcll construction method:AUGERS consimctiou to the following:
(i.c.au€ct.roan•,cable.direct push ctc.) '
Division of Water Resourivs,Underpvund Injection Control Program.
FOR WATER Sb"PPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC27699-1636
13a Yield(Rpm) 'Method of tact 24c.For Water Supply&injection Wells:
Also submit one cop)' of this form within 30 da}'sofcompletionof
13b.Dlsinfietion type:,, „-m_ Amount: well constmclion to the county licallh dclinatnrnt of the countyA%-Ixtc
- - constrtctefl. j
Fonn G1,1`4 Korth Carohm MWntciaof Environment ardN:mtral Rcuiurccs-Divi0on of Waicr'ReSoureM Rcviscd August ZQI3