_Well Construction - GW1_20230327 (18)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JeffreyGrant
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4328-B 40.5 ft. 44 ft•
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
JG Drilling,LLC FROM TO DIAMETER THICKNESS MATERIAL
fL ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#:WM0601250 FROM TO DWMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 fL 40 ft- 1.5 m, .25 Steel
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunicipal/Public 40 ft- 44 ft- .75 in.
.006 •25 SS
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
-)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft- None
x Monitoring DRecovery ft. ft.
Injection Well: - ft. ft.
Aquifer Recharge rIGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormwaterDrainage ft. ft. None
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) rITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) n Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
ft. ft. Soil samples were not collected.
4.Date Well(s)Completed:3-14-23 Well ID#GW-2 ft. ft.
5a.Well Location: ft. ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4800 Murchinson Road, Fayetteville, 28311 ft. ft. MAR 2 7 .ZRJ
Physical Address,City,and Zip ft ft. I Inf.!
Cumberland 0429-33-2447 21.REMARKS ,ni,>,1,'-'°"_' � vv
LJ„
County Parcel Identification No.(PIN) Temporary well.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.105977 N 78.921841 W 3-16-23
6.Is(are)the well(s)13Permanent or ElTemporary Signatur f OeMed I CoWractor 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: Dyes or X)Ne with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the 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:One SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 44 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferenl(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:40.56 (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: 1•5 m.
( ) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
Direct Push 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