GW1-2022-09078_Well Construction - GW1_20220927

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
All American Well & Pump 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
18 ft. 92 ft.
David Howard
fr. ft.
NC Well Contractor Certification Number 15.OUTER CASING for TEL cased wells OR LINER if a licable)
2916 FROM TO DIAMETER THICKNESS MATERIAL
ft. fL in.
Company Name
2022-��27 16.INNER CASING ORTUBING eothermaldosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) *1 ft- 72 fL 4 in. Sch40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunicipaVPubhc 72 ft. 92 fL 4 in- 12 Sch40 PVC
Geothennal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) ill.GROUT
hTiaation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- Cement Pouring
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage 70 ft• 93 tt Gravel Pouring
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Retu m) M Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,wil/rock type,grain size,etc.)
0 ft- 1 fL Top Soil
4.Date Well(s)Completed:09/22/2022 Well ID# 1 ft. 20 ft. Red Clay
5a.Well Location: 20 ft. 58 ft. Red Sand
5908 Dottie Cir,Lot19,Hope Mills,NC 28348 58 ft. 60 ft- Black Clay
Facility/Owner Name Facility ID#(if applicable) 60 ft. 92 ft. Coarse
Paradise Homes 2094 Orville St, Fayetteville, NC 28312 ft. ft.
Physical Address,City,and Zip ft. ft.
Cumberland 21.REMARKS
County Parcel Identification No.(PIN) NONE
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification•
34 887 567 N 78 866 316 W ,
Z24" ��,, 09/26/2022
6.Is(are)the well(s)OPermanent or [DTemporary Signature of Certified Well Contractor — 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: OYes or E)No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under 921 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: 92 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 18 (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:6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Rotary above,also submit one copy of this form within 30 days of completion of well(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 M—I ce. ;—C.,.ter.RaleS¢h_NC 2 769 9-1 61 6
13a.Yield(gpm) 20 Method of test:Bailing 24c.For Water Supply&Injection 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: HTH Amount: 2 LbS 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