GW1-2022-07873_Well Construction - GW1_20220823

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. Well Contractor Information:
Sanford Sweeting 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2082-A
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Applied Resource Management FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. I in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UC,County,State, Variance,etc.) 0 ft. 225 ft. 1 in. SDR — 1 1 HDPE
3.Well Use(check well use): ft. ft. in. fl
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft, ft in.
Geothermal(Heating/Cooling Supply) [:]IResidential Water Supply(single) ft R• in.
�Industrial/Commercial [:]IResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
INon-Water Supply Well: 0.0 ft. 225 ft' Bentonite Tremmie
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 01 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 01 Stormwater Drainage
Experimental Technology [:]I Subsidence Control
Geothermal(Closed Loop) [:IITraeer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,wil/rock e,grain size,etc.[:]I Other(explain under#21 Remarks) ft. ft.
0 35 Hard multi colored clayey silt with quartz
4.Date Wells)Completed: 8/04/2022 sell ID# 35 ft. 50 ft. Corse sand, some clay layers
5a.Well Location: 50 ff 70 ff Multi grained sand,very little silt
70 ff 100 ft Silty clay, some sand
Facility/Owner Name Facility ID#(ifapplicable) 100 ft. 120 ft• Multi grained sand with silty clay
105 Pavilion Way, Southern Pines, NC 28387 120 ft' 140 ft. Silty corse sand with silty clay layers
Physical Address,City,and zip 140 ft' 170 ft Grey corse sand with silty clay layers
Moore 857100496541 2L REMARKS
County Parcel Identification No.(PIN) 170 ft. 225 ft. Corse sandy silt
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 225 Pt. Bed Rock
(ifwell field,one lat/long is sufficient) 22.Certification:
N w '!Y ,� �� 8/04/2022
6.Is(are)the well(s):QlPermanent or [3ITemporary Signature of rtitied Well Contractor 61 Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3IYes or [3 No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.
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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3CJ)200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing use'—" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells: hi addition to sending the form to the address in 24a
above, also submit one 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
13a.Yield(gpm) Method of test: 24c. For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016