GW1-2022-10507_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford 14.WATERZONES ::1
FROM TO DESCRIPTION
Well Contractor Name ft. ft
3270 q ft. ft
NC Well Contractor Certification Number _ 15.OUTER CASING for mniti cased welts OR LINER if a licable
�.3-,... FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. fG f, in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
N 0 V 1 8 2022 FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: fa ft in
List all applicable well permits(i.e.County,State,Yariagrp In�ectiori,. rC �� ' Un 0 5 2° SCh 40 PVC
t17�v :•���;...�jF•.1�. :.•:�..�a:u� ft. I ff. I in.
3.Well Use(check well use):
17.SCREEN I
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 fi- 15 ft. 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑rri ation 0 ft' 3 ft. Grout Pour
Non-Water Supply Well:
MMonitoring ❑Recovery 3 ft. 4 ft. Bentonite Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERLIL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4 It. 15 ft Sand Pour
ft. ft.
❑Experimental Technology ❑Subsidence Control ,'20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soll/rock n size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 0.50 IL Asphalt
4.Date Well(s)Completed:
11/01/2022 Well ID#M W-3 0.50 ft. 1.5 ft. ABC gravel
1.5 IL 5 ft Orange/gray sandy clay
5a.Well Location: 5 ft 11 ft. Gray/tan medium sand
TForce Project Flash n/a 11 fL 15 ft. Gray sandy clay
Facility/Owner Name Facility ID#(if applicable)
ft. ft
531 S Eastern Blvd, Fayetteville, NC ft. ft.
Physical Address,City,and Zip 21.REMARKS
Cumberland 0436-98-8492
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer' cation:
(if well field,one lat/long is sufficient)
35.036919 N 78.866624 W (k-o YIY4'4
Signature of Certified W u Contra t r Date
6.Is(are)the well(s): 21'ermanent or ❑Temporary By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
with I SA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or KNo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 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 constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 15 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: n/a (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Solid fli ht 24aabove, also submit a copy of this form within 30 days of completion of well
au er
12.Well construction method: 9 9 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&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013