GW1-2022-07657_Well Construction - GW1_20220818

WELL CONSTRUCTION RECORD For Imcmil Use ONLY:
This form can be used for singk or mullipk gills
1.Wdl Contractor Information:
Rich Lemire fsrZ N r—, .c FROM TO OF-Scl ill"0
11`ell Contrtctot Naim Fm ! •.t R. ft.
AUG i 6 2022 ft. n.
2593A !
NC Well ComricrorCenifttal ion Number ,A&VUTP.R ING faraiGRi�casc 4kils ORL'tlY>tR(it a lkable
FROM TO DIVVIETER THICKNFCS MATERIAL
SAEDACCO Inc 1f1ECii>fiE°ot�1 P ',;ny alt'itg Urtd 0 ft. 34 ft. 6" in. SCH-40 PVC
Company Nallic t6.`INI FR.. ING OR"SING";er tberanat rkisrdaar
FROM I TO DLANIETER TIIICIGNM MATERIAL
2.Well Construction Pethnit 0: 0 ft, 45 ft. 2" hL SCH-40 PVC
List a11.717p rable a,-11 permits(i.r.counn•.Scar.t arirtrrce./rryardat eje.)
fl. ft. in.
3.1tr'cll Use(check well ose.): 17.'SF Ri�N
Water Supply Well: FROM TO A►A�/F,TfR SLOT SO7F, I 1rnIC1(NttiS 11MATFR1A1:
0Agrrultural L muoicipalll "ic 45 ft, 50 R. 2" ia, 010 SCH-40 I PVC
f3Geothcimal(HentinpJCooling Supply) 011esidential 1L`atcr Supply(sinNte) ft• ft.
Gll n•i ndust6allConimcal 011midcnlial Wiwr Stlppb,(shared') FROMO TO UT
MATERIA[ E�tPI.�CENFVTS1ETnOD tC A\tO11vT
Dirrigittion 0 fa. 41 f1. PORTLAND 0 POURED
Non-Water Supply Well: A. fI.
MiNlonitoring ORccovrry
Injection%Veil:
OAguifcr Recharge O6ronn(1w tree Rentcdiation t9.SANtb1C.RAV!t rkac(4111a slkn$Ir
QriguitcrStorageairdRccotrr}' OSal Salinity 8amcr VRnM m sIATk:Rt'kt• VMPI.A(`.tMVVTM1;TNQ11
43 A. 50 ft. .SAND #2
OAgtiifcr Tcst OStomtratcr DrainaSc ft. h.
0EV. cr mcntal Ttthnolo& Otiahsidcricc(.omml
"20;DRHAJNG'LOG(att,.eh iddilionetahrel 'N'nccctsart +
❑Geotherotal(Closed Loop) OTracer ;Rost TO nFJCitiPttU\f(»tor h�rtlnrf`it fYntttra n sic Me.
OGeotheniwl(Heatik4)too1ine Return) OOther tex lain under 021 Behar) 0 ft. 5 f1. GRAY SILTY SAND
5 ft. 15 ft. REDISH SILTY SAND
4.Date Wrtl(s)Completed: 7-28-22 WdlIDOD-2 15 ft. 32 fi, SAND/SILT
Sa.Well L C11thin: 32 ft, 34 tl. BLACK CLAY
CIRCLE K #2723027 ft. ft.
Fa614yl %vmr Nann; Facilh ID11(if applirnblc) to. ram. ft.
2001 Skibo Rd., FAYETTEVILLE, NC, 28314 A. ft.
Plkyskal Adders.City,and Zip Ii.R1PIitARKS'.
CUMBERLAND Bentonites seal from 41-431.
Connq Parvet Idstdirk-ition Nct.(PIN)
-Ali.Nititudc and Imoginide in degrecsl'ruinuteslsccondts or decimal degrees: 22.Certification:
(if well k1d,one Ird7nt is snfl ci rtn
��
,,. �,,,:f...� 7,28,2022
SigmttimafCcni _v diContrartor Datc
6.Is(are)thewell(s): ZPerimment or t7Temporar'y rlr signing this fottn,I hereifr erflifr that the udlisl tern fmwe)-mitimcred in meorrlsmee
with'1 SA XCAC 02C,0100 0'1 A A`CitCO2C:0200 Well Crtttsirrtt:rion ftan4ards rent)irbol(r
7.is this a repair tb an cxistinu well: OVes or EiNo rcVy of flits rerfsni hat hern pirlIfh d rn rhr hell nnvtrr.
If this is a re pair,fall entr knrmvr well eonsinfrilon btfitowwrion arul explain ria:rutaue of file
relmir twirler 021 remarks.welim or rm the lwk of this farnt. 23.Site diagram or additional well detalW
You may-6use Ilk•back of this page to provide additional well site details or well
8.Number of wells oo►structed: 1 consituctiondetails. Ybu`irriv aLs6 altach additional pabtes if i►eLessaty.
Par mutely e i(geuhm at arAt-roarer sulrlffs tolls AD'I,Y srirh fha some ronstrursioir,you Carr
salwnifhneform. SI!nmirrAl, LNSTUCTlO
9.Total well depth below land surfaces 5o (R;) 24a. For All Wclls:, Subnut this thou i%itbin 30 days of completion of well
Porrnultiple wells l,Wall(leprhi ffili wren texmnpfe. 0.2m.'a vl2(4W) construction to the folloning:
10.Static water level below top of casing: 9 (n,) Division of Water Roan rom,Information Processing Unit,
If uyver level Is al-eve('akx,lore"+" 1617 Mail Sort iM Ccnfcr,Ralcigli,NC 27699.1617
11.Borehole diametcr.12.25"/6" (in,) 24b.Far luitrdon We11s ONLY: 1n addition to sending the foml to the addrm in
24aabove. also submit a cope of this foim within 10 days of completion of%sell
12:`NYell construction Method: AUGERS/MUD ROTARY construction to the following:
(i.e.anger.rolan•.cable,direct piste etc.)
Division ofN'alcrRcsourccs,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276"-1636
13a Yidd U,q►ni) Method of tests 24c.For Water Supply&Inlectiiln`Wells:
Also submit one cope of this form within 10 daysofcompletionof
13b.LtisinfiYtion ripe: _ Amount: well constrnotion to the courav hcnlih depadrncnt of the counh•.whe n:
constructed.
FameGt1`-I North Catotitta CI`Wiina-m of Envinaninciu and`aturtl Resources-Division of Wr{tciResourcm Revised august'N13