GW1-2022-07650_Well Construction - GW1_20220818

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER ia:WATERzorlRs.m _
Well Contractor Name FROM TO ft DESCRIPTION
ft.
A - 4475 ee. ! ft. ft
NC Well Contractor Certification Number " 15.'OIJ`rER CASING for'miilh�cas6il $lls`OR,L'INER"if a licable
GEOLOGIC EXPLORATION AIJ 1 s �V 2022 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in.
Company Name
e ' ,J6.INNEWCASING�OR:TUBING `"etitLermelelos6d`loo
2.Well Construction Permit#: Ii1�DfRr��3'1 �' ,�� .RdRO FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County, tare,Variance,etc.) 0.0 ft. 2.0 % 2.0 to SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: -17.,SG'REEN. .r ah<��
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2.0 ft 12.0 it' 2.0 1°' .010 SCH 4.0 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '18:"GROUT,,.,.
❑Irri ation ❑Wells>100,000 GPD - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 1.0 fL PORTLANDBENTONrrE SLURRY
[EMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
J%9 SAND/GRAYEL'PACKP�if
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 1.5 ft- 12.0 it 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 2o.;1)RTI LING;LOG'attacb addiHodahsheets itnecesse. ._...
❑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 ft ASPHALT/GRAVEL
4.Date Well(s)Completed: 06/23/22 Well ID# MW-9 1.0 ft. 10.0 ft BROWN SILTY CLAY
5a.Well Location: 10.0 ft 12.0 ft" TAN SANDY SILT
STRICKLANDS GROCERY tr. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2376 CEDAR CREEK ROAD FAYETTEVILLE 28312 ft. ft
Physical Address,City,and Zip
ft. ft.
CUMBERLAND
County Parcel Identification No.(PIN) BENTONITE SEAL-1.0-1.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 00' 00.00" N 780 48' 29.14" W �
07/11/22
6.Is(are)the well(s): OPermanent or , ❑Temporary Signature ofCer ified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I'JNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
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: 12.0 (ft.)
For multiple wells list all depths ifili ferent(example-3@200'and 2@100) Submit this GW-1 within 30 days!of well completion per the following:
10.Static water level below top of casing: 5•0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwarer level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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 l
24c.For Water Supp1Y 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 roducin over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources; Revised 6-6-2018