GW1-2022-01825_Well Construction - GW1_20220210

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ronald barronI+�WATER3ZOIHES..anu l
Well Contractor Name .FROM S TO. DESCRIPTION -
ft. ft. .
2091-A
ft. ft.
NC Well Contractor Certification Number 43.ODU1 R,GASINGT fo►.mr"`li i3=cira 0ee0i!OIRILINER€ff.ii"
Piedmont Industrial Services FROM TO DIAMETER THICKNESS MATERIAL
ft ft. in.
Company Name '
16;I1VNER{GASINGM...UB1NGi" { d4d-9 :"f
2.Well Construction Permit#•N/"A' FROM' ; TO. DIAMETER :',THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc) +3 ft- 14 ft-`. 2 in. Seh 40 PVC
3.Well Use(check well use): ft. ` ft.1 in. ,
tt173SCREEN�, "
'JNn
Water Supply Well:
FROM. TO ; DIAMETER SLOT SIZE ,.THICKNESS MATERIAL
ricultural 13Municipal/Public 14 tt ,::29 ft ' 2 in sU1'0 SCh 40 PVC
othermal(Heating/Cooling Supply) ,DResidential Water Supply(single) ft. ft. in.
- k
ustrial/Commercial Residential Water Supply(shared) .
Stion FROM TO MATERIAL ~' EMPLACEMENT METHOD&AMOUNT
Water Supply Well: j !O ft. ft• concrete Poured
onitoring Recovery10 ft. 12 ft• 3/8 Bt>nt:drips Poured
ction Well: ft ' ft.uifer Recharge 13Groundwater Remediation
'419dSA VD/GRA`VEuifer Storage and Recovery Salinity Barrier FROM TO„ ;: MATERIAL EMPLACEMENT METHOD
uifer Test C)Stormwater Drainage 12 . 29 ft. Fifter send Tremie
perimental TechnologyaSubsidence Controlothermal(Closed Loop) 13Tracerothermal Heating/Cooling Return) Other(explain under#21 Remarks i FROM To DESCRIPTION color,hardness,soiUrock a rain size,etc
p ft 4 ft. -tan orange sand
4.Date Well(s)Completed:1-27-22 Well ID#MW-2 4 ft 5 ft-
waste
5a.Well Location: 5 ft. ft. oran a clayey Slit
City of Fayetteville N/A g ft- 119 ft- browll,1tan sand
Facility/Owner Name Facility ID#(if applicable) 19 ft. 2g ft. ' gown,tan sand
400 Milan Road Fayetteville, 28301 ft. ` ft- ST @ 29
Physical Address,City,and Zip
Cumberland N/A 2IiREMARKS i _�_.
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:
35.,07227545 N -78.86058632 W
2-3-22
6.Is(are)the well(s) x Permanent or DTemporary 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: [3Yes or';®x No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and i-ipinln the nature of the copy of this record has been provided to the well owner.O r BR+p e
repair under#21 remarks section or on the back of this form. _ _. F f 1
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal W011stlaVing the same You may use the back of this page to provide additi e�lsAe details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach a`d3i
drilled:N/A SUBMITTAL INSTRUCTIONSt
' r
> -!A
9.Total well depth below land surface: 29
(ft.) 24a. For All Wells: Submit this form Aft ay-;' le ion,ro well
For multiple wells list all depths iftliferent(example-3@200'and 2@100') construction to the following: 1 d �iS Fo,if
18.8 Vivii ha
10.Static water level below top of casing: (ft.) Division of Water Resources,lpferm1.;rtnrn rtmessatg t E
If water level is above casing,use"+" 1617 Mail Service Centel',Raleigh,NC 27699-)P
11.Borehole diameter:.$ (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger above, also submit one copy of this form within 30 days of completion of well
12.Well construction method:
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
- - Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: 24c.For Water Sunoly&Infection 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.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016