GW1-2023-02204_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if ii Irlicable
GEOLOGIC EXPLORATION FROM TO DIAMETER TIHCKNESS MATERIAL
ft. fr. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO HI DIAMETER TCKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,flariance,etc.) 0.0 ft- 30.0 ft. 2.0 in' I SCH 40 PVC
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30.0 ft' 40.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EDIPLACEMENT11f ETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 26.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery fr. ft.
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
❑Aquifer Test ❑StonnwaterDrainage 28.0 ft- 40.0 fr. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control fr. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 fr 2.0 fL BROWN SAND
4.Date Well(s)Completed: 01/19/23 Well ID# MW-5 2.0 ft 25.0 fr• ORANGE SANDY CLAY
5a.Well Location: 25.0 ft 40.0 ft' ORANGE.SAND
ONE HOUR CLEANERS ft. ft. �;.�.w F,; ,•.'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
MAR
1303 FORT BRAGG ROAD FAYETTEVILLE 28305 ft. ft.
Physical Address,City,and Zip fr. ft
CUMBERLAND 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-26.0-28.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 03' 28.30" N 780 54' 06.54" W 01/23/23
6.Blare)the well(s): (EPermanent or ❑Temporary Signature of Certified Well Contractor Date
Hy signing this form,1 hereby certify that the irell(s)was(here)consirucled in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 15A NCAC 02C.0100 a•15A NCAC 02C.0200 11'ell Construction Standards and that a copy
ljthis is a repair,fill out known well construction injbrinmtion and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section or on the back ofthis 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 construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40.0 (ft.)
p'or multiple wells list all depths tfdi,/jcrent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 36.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+"
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in,) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:. Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018