GW1-2022-03224_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: i
G
JACOB MESSICK 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft. �
A - 4252
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased.wells 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.UIC,County,State,Variance,etc) 0.0 I'L 40.0 ft• 2.0 'n' SCH 40 PVC
3.Well Use(check well use): ft' ft' in.
Water Supply I 17.SCREEN
FROM TO' DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 40.0 r`- 50.0 fL 2.0 in.
.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 ❑Wel Is>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 36.0 ft' PORTLANOBENTONITE SLURRY
15Monitoring ❑Recovery ft. ft.
Injection Well: R. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 38.0 ft- 50.0 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,grain size,etc.
0.0 ft. 5.0 ft. TAN/BROWN SAND
4.Date Well(s)Completed: 02/14/22 Well ID# MW-29B S.0 1" 20.0 ft• TAN SAND
Sa.Well Location: 20.0 rt• 50.0 I'L FINE TAN SAND
MERITOR PUROLATOR
Facility/Owner Name Facility ID#(if applicable)
3200 NATAL STREET FAYETTEVILLE 28306 rt' ft. ?02?
Physical Address,City,and Zip
CUMBERLAND 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-`36.0 38:0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lit/long is sufficient) 22.Certification: � �}�
350 00' 46.38" N 780 55' 17.03" W Ono"10'7 02/21/22
6.Is(are)the well(s): 151'ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing thir.itrnt,I hereby certify that the wells)teas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!9No 15A NCAC 02C.0100 or 15A NCAC 02C,.0200 Well Construction Standards and that a copy
If this is a repair,fill out known trel/construction information and explain the nature of the of this record has been provided to the trel/ouner.
repair under»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 1 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: 50.0 (ft.)
Tor nuhiple ire/is list al/depths ifdi,/ferent(example-31t 00'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
15.0 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'
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 department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producingover 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:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018