GW1-2021-00539_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Justin Radford l4.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
GRI 12.45 ft• 20 ft orange/brown silty medium sand
ft. ft.
NC Well Contractor Certification Number 15.OUTER CANG(for mAdwellsOffi f iMET
cMaAblTeT RL1L3270 FROM DI E S
ft. ft. in.
Company Name
td:INNER CASING Olt TUBING'`eiithermal closed=loo'"
2.Well Construction Permit#:NA FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) 0 ft• 5 ft. 2 1 . Sch 40 PVC
3.Well Use(check well use): ft• ft. tn.
Water Supply Well: 17.SCREEN 24
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipat/Public 5 ft. 20 ft• 2 1- 0.01 Sch 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared)
`Ig:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 3 ft Grout Pour
Monitoring ®Recovery 3 ft- 4 ft' Bentonite Pour
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRA'l!E1:PACK=it a' ticable ., /G,,, .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage 4 It. 20 ft- #2 Sand Pour
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer X DRILLING;hOG_attach additional sheets if necessa '" „ �,�i
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness softeck type,grain size etc.
0 ft 6 ft tan medium sand
4.Date Well(s)Completed:11/08/2021 sell ID#M V V`p'-2 6 ft 20 ft orange/brown silly medium sand
5a.Well Location:
401 Express Shop 0-00-0000026075
Facility/Owner Name Facility ID#(if applicable)
4302 Fayetteville Road, Raeford, NC 28376 ft ft
Physical Address,City,and Zip
Hoke 6944500001006 21.REMARKS r.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: WTr
35.0062523 N 79.17826030 W "' AT"'F'"'1 KJN021
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor 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: 03Yes or JMNo with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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#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(1) SUBMITTAL INSTRUCTIONS,
9.Total well depth below land surface: 20 Vt-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 12.45 (ft.) Division of Water Resources,Information Processing Unit,
If enter level is above casing,use"+„ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Aug ers above, also submit one copy of this form within 30 days of completion of well
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 SDDDIV&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fort 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