GW1-2022-10509_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.
FROM WATER FROM
FROM TO DESCRIPTION
Well Contractor Name ft. ft
3270 A ft. fL
NC Well Contractor Certification Number '` �, p L i V a.m, �y 15.OUTER CASING for multi-cased wells OR LINER if a _Iicable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. , , ft, f, in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit '; Uni t 0 ft 5 ft 2" 1° sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,In)Wo ta'.r
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: . FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft 15 ft' 2 1n. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 & 3 % Grout Pour
Non-Water Supply Well:
©Monitoring ❑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 MATERIAL EMPLACEMENT METHOD
4 ft 15 ft Sand Pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,herdnes soil/mck type,grgin size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 0.50 ft Asphalt
4.Date Well(s)Completed: Well ID#
11/01/2022 MW-1 0.50 fL 1.5 ft ABC gravel
1.5 ft, 5 ft. Orange/gray sandy clay
Sa.Well Location:
TForce Project Flash n/a 5 ft. 11 ft. Gray/tan medium sand
11 ft 15 ft Gray sandy clay
Facility/Owner Name Facility M#(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•Certificatio
(if well field,one laUlong is sufficient)
35.036919 N 78.866624 W 117,01z"-
Signature of Cert' ed Well Contracto Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby cerufy that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
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: 1 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 AR Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi.Q'erent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: n/a (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 Iniection Wells ONLY: In addition to sending the form to the.address in
au er Solid fli ht 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 9 g 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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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
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