GW1-2021-02161_Well Construction - GW1_20210721

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford 14.WATERZONEs ;
FROM TO DESCRIPTION
Well Contractor Name JUL 14 1 20 8 ft. 9 ft. i Orange medium sand
3270 A o�ssin9 Uri ft. ft.
NC Well Contractor Certification Number n pr 15.OUTER CASING for:multi cased;wells iORLINER a licatile
IriJGrCf�aD�^i't�g�o1ion FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. rL ft in.
Company Name
16 INNER CASING OR TUBING:.1 ebthermwl:clb ed-loo'
WM-061175 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 5 fl- 2° in. sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. In.
3.Well Use(check well use): 17:,SCREEN
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE f THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 5 fL 15 ft 2 In- 0,010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1i3'GROUT
FROM TO MATERIAL j EMPLACEMENT METHOD&AMOUNT.
❑Irri ation 0 ft. 3 fL Grout Pour
Non-Water Supply Well:
3 ft 4 ft Bentonite Pour
oMonitoring ❑Recovery
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK'if a RcBble
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
8 ft. 15 ft. ;Sand Pour
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach addidonal.aheet's'ifneceas
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,sowrock type,gran size,etc
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 ft, 2 ft. Gray fine sand
4.Date Weil(s)Completed: Well ID#
05/24/2021 MW-10 2 ft. 8 ft. Orange sand clay
8 ft 9 ft. Orange medium sand
5a.Well Location:
9 ft. 15 ft. BlacW gray clay
Gray's Creek Superette 0-000036605 ,t• fL
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
6353 NC Highway 87, Fayetteville,"NC ft. ft.
Physical Address,City,and Zip
31:REMARK ,
Cumberland 0441-48-2904 i
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
34.90112 N 78.852486 w 06/09/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 15 (ft.) 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: 6.46 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
6" i
11.Borehole diameter: (in.) 246.For Infection Wells ONLY: In addition to sending the form to the address in
u 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 6 Steel Flight Auger 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
24c.For Water Supply&Injection Wells:'
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013