_Well Construction - GW1_20230327 (19)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Jeffrey Grant 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4328-B 31 ft. 35 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a lica6le
JG Drilling,LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
WM0601250 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.VIC,County,State,Variance,etc.) 0 ft. 31 ft 1.5 tn' .25 Steel
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 31 ft- 35 ft• .75 in- .006 .25 SS
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial EIResidential Water Supply(shared) 18.GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft- None
X Monitoring DRecovery ft. ft.
Injection Well: -- -
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENTNIETHOD
Aquifer Test [3StormwaterDrainage ft. ft. None
Experimental Technology C3 Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rl Other(explain under#21 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-3 ft. ft.
5a.Well Location: ft. ft.
ft. ft. o' j
Facility/Owner Name Facility ID#(if applicable) ft. ft. M Y
4800 Murchinson Road, Fayetteville, 28311 ft. ft. MAR z d 2023
Physical Address,City,and Zip ft. ft. c -- for .^?d3'zln•. Unit
Cumberland 0429-33-2447 21.REMARKS
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)oPermanent or X]Temporary Signatur f CW&fted W 1 Co ractor 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: E]Yes or XMNo with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and drat 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 io the well owner.
repair under#21 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: 35 VO 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(erantple-3@200'and 1@100') construction to the following:
10.Static water level below top of casing:31.03 (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 (in.) 24b. For Infection 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.) i
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 Sunoly& 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: 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