GW1-2022-03216_Well Construction - GW1_20220311

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information: j
JOHNNY BURR 14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
i
A - 3098 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-casedwells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
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.U1C,County,State,Variance,etc.) 0.0 ft. 30.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PPy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30.0 r" 40.0 ft' 2.0 in- .010 SCH 40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT M EPHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 24.0 ft. PORTLANDaENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. tt.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 28.0 ft• 40.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control fr. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilhnck type,grain size,etc.
0.0 ft• 0.5 ft• ASPHALT
4.Date Well(s)Completed: 02/09/22 Well ID# MW-4 0.5 ft• 6.0 ft• GRAY SANDY CLAY
5a.Well Location: 6.0 ft' 28.0 ft' ORANGE SANDY CLAY
ONE HOUR CLEANERS 28.0 ft. 40.0 ft. TAN SANDY CLAY
Facility/Owner Name Facility ID#(if applicable) ft. ft. _.
1303 FORT BRAGG ROAD FAYETTEVILLE 28305 ft. ft.
Physical Address,City,and Zip ft. ft. MAR 1 7
C U M B ERLAN D 21.REMARKS
Comity Parcel Identification No.(PIN) BENTONITE SEAL-24.0-28.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
350 03' 28.19" N 780 54' 06.61" W 02/18/22
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature of Certified Well Contractor Date
By.signing this mn,l hereby certify tharthe well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: OYes or l!9No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ij this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under k'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 construction info
construction,only I 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.)
For multiple wells list all depths ifdijJerent(example-3@000'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 17.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lf'water level is above casing,use"+"
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control (IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
AUGER
12.Well construction method: 24c.For Water Supply and Open Loop 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018