GW1-2022-03220_Well Construction - GW1_20220311

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: {'
1.Well Contractor Information: j
JOHNNY BURR 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 3098 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.1NNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 80.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN _
PP y FROM TO DIAMETER 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. I in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 24.0 ft' PORTLANDBENTONITE SLURRY
INMonitoring ❑Recovery
Injection Well:
❑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 rt• 40.0 rc, 20-46 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0.0 ft. 1,0 n- BLACK TOPSOIL
4.Date Well(s)Completed: 02/09/22 Well ID# MW-3 1.0 ft. 6.0 ft' ORANGE/RED CLAY
5a.Well Location: 6.0 ft- 13.0 It. WHITE/GRAY CLAY
ONE HOUR CLEANERS 13.0 ft- 30.0 r' ORANGE SANDY CLAY
Facility/Owner Name Facility ID#(ifapplicable) 30.0 rc' 40.0 ft. TAN SANDY CLAY
1303 FORT BRAGG ROAD FAYETTEVILLE 28305 ft. ft'
Physical Address,City,and Zip ft. ft. MAR 1 202?
CUMBERLAND 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-24.0-28.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 03' 28.19" N 780 54' 06.61" W 02/18/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,1 hereby certify that the uvell(s)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MIND 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the hell ou ner.
repair under#21 remarks section or on the back of this farm.
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.)
Far multiple wells list all depths ii(Viflereni(example-3(a 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
17.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f hater 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 127699-1636
12.Well construction method: AUGER 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 producinQiover 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-161 1
13a.Yield(gpm) Method of test:
I
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018