GW1-2022-03221_Well Construction - GW1_20220311

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 3098
ft. ft.
f '
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'.wells ORLINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER MA THICKNESS TERIAL
I. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
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. 30.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
PPY FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30.0 It- 40.0 ft' 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 24.0 ft PORTLANDBENTONITE SLURRY
15Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 28.0 ft- 40.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑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,sail/rock type,grain siu,etc.
0.0 ft• 0.5 ft. ASPHALT
4.Date Well(s)Completed: 02/07/22 Well ID# MW-2 0.5 ft• 10.0 ft• ORANGE/YELLOW SANDY CLAY
Sa.Well Location:
10.0 ft' 18.0 ft' ORANGE SANDY CLAY
ONE HOUR CLEANERS 18.0 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
,
CUMBERLAND 21.REMARKS
County 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 lat/long is sufficient) 22.Certification:
350 03' 28.19" N 780 54' 06.61" W d" U 02/18/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONO 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and That a copy
lfthis is a repair,fill out known well construction information and explain the nature oJ'the of'ilus record has been provided to the well owner.
repair under 21 rentarks section or on the back of this Jornt.
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-1 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)
/oitr multiple ire//s list a//depths iit'd &rent(example-3 a 200'and 1 rid 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),
If Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if 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 27699-1636
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 departIment 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 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Font G W-I North Carolina Department of Environmental Quality-Division of water Resources Revised 6-6-20I8
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