GW1-2022-03222_Well Construction - GW1_20220311

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft. I. ;
A - 3098 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for -cased wells OIL if a licable
multi
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING Neothermal 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 "' I SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: F7R.OSM REE TO DIAMETER� SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30.0 ff 40.0 ft' 2.0 r"' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/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
[NMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑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 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,soil/rock type,pmin size,etc.
0.0 ft. 0.5 ft. ASPHALT
4.Date Well(s)Completed: 02/08/22 Well ID# MW-1 0.5 ft. 8.0 ft. RED/ORANGE CLAY
5a.Well Location: 8.0 ft' 30.0 "' RED/ORANGE SANDY CLAY
ONE HOUR CLEANERS 30.0 ft. 40.0 rt. TAN SANDY CLAY
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1303 FORT BRAGG ROAD FAYETTEVILLE 28305 ft. ft.
Physical Address,City,and Zip ft. ft.
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:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 03' 28.19" N 780 54' 06.61" W AR �44 8122
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,1 hereby certify ihal'the Ivell(s)spas(were)cons•irdcied in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or l5A NCAC 02C.0200 Well Construction Standards and that a copy
U this is a repair,fill out known well construction information and explain the nature of the of ihis record has been provided to the well owner.
repair under 1111 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 Ovet 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.)
h'or nudup/c wells lint al/depilrs q'difjereni(example.3 rr 100'and 2 c@t l00') 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
/(water level is above casing,use"7
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 Opens 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 producingiover 100,000 GPD: Copy to DAR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: 4
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Form G W-I North Carolina Department of Environmental Quality-Division of Water Resource's Revised 6-6-2018