GW1-2022-07659_Well Construction - GW1_20220818

WELL CONSTRUCTION R-ECORD For ImcntilUscON1Y:
This form can N used for sinrk or mullipk%cells
L.Well Contractor.infor'mation:
AL WATER ZONCS
Rich Lemire FROM TO DF5(,-RIPt10N
N'c11 Caitirictor Name R ;V. D (I. (I.
fl. ft.
2593A
NC�1rdl Comraclor Certification NtmlectAUG ' nh /n t5.OUTER CASING for inolti-cow.)wens OR L7KER it'a lkahk
p.U� `022 FROM m PIADiF.TER TntCAfiiSS MATFRTA4
SAEDACCO Inc 0 ft. 5 ft, 2- r .in. SCE-40 PVC
Crlt9eiia^ ':�„:Qaasa UrtR
Coitgraq N911k D%A fi130 16.!INNER GASING`OR TUBING eot®erwal clttscd ton
FROM TO I)LAMF.TER. THICKNESS MATERIAL
2.Well Construction Permit#: ft. tt. ln•
Litt till nlytlirable urll pr mite(ix.Comttt':Su all..1�•iriawe.h�aoai rtr.)
n. a.
3.Well l)sc(check well use):
Water Supply Well: FROM I TO I DIANrFTBR I.OTSIss MATI.RI41:
OAgricultural bMunicipalil-lublic 5 (1• 15 rt. 2" in• .010 SCH-40 PVC
OGeothermal(Ncating.`Cooling Supply) OResidential Wiler Supply(single) ft. ft.
OindustriallComntcn:ial 011csidential Water Supph•(shared) 1FAROGROVf 70 1 EAiPLAcrmF-_.T MI:TDOD&ASIOlE\T
❑Irri anion 0 ft. 2 t1. PORTLAND i POURED
Non-eater Supply Werl:
6tlManitoring 17Recotrq•
Injection Well:
OAquiferRectiirgc DGroundwalerRcntcdi:nion 19.SAND/GRAueLPACKfir )licablr
FRO a1 TO I MAT):1411i. Fm I..If' IVNTMrTFI0I1
OAgniferStor igc and Renner' ❑Salinity Harrier 3 fl. 15 ft. SAND #2
OAquifcr Tcst DSlommatcr Drainage
A. It.
DF.ylcrimcntal Tcchnology ❑Subsidcr)cc Cordrol
120.DRtl UNG1:OG(attach additionalsllrels If neccimn
❑Geodlemial(Closed Loop) OTracet GROhI TO nFSCRIPTIO.1ev18r.A1rHncsrstiR'mctits' n r.Hr:!
Ot rotlucnna)(Neatina)Caoline Retuin) 00ther(explain under 021 Remarks) 0 (1. 5 a. GRAY SILTY SAND
5 ft. 15 ft. REDISH SILTY SAND
4.Date,Well(s)Completed: 7-28-22 W ell ID#Mtu-7
ft. rL
Sa.Well Ltleatltln:
CIRCLE K #2723027 ft. ft.
Facilit)lOwricr Flans Facility IDk(if applimhlc) ft. ft.
2001 Skibo Rd., FAYETTEVILLE, NC, 28314 ft. fl.
Plnsical Address_City.and Zip 2L Rtl1MARK3'
CUMBERLAND Bentonite seal from 2-3'
(.Dairy I12rcelId'.1111 c:d)onNo,(PIN)
Sh.iattitude anti Longitude in dcgirc%/minutcslsceondsnr decimal degrees: 22.Certification:
(ifuel)frcld,one L*Iot>_f;is sunicku)
W 7 f 28j2022
St�t>aturc otCcai _.Yell Contmctor Dale
6.Is fare.)the well(s): -ZIPermanent or OTemporar)' fA eilninp lhif f ton,f herr.6r(•edify thru Me tirllis)urns fmwr)tstrami-jed iv aceordanee
Idth 15,1,VCAC 02C.0l(k)or l SA NOW(11C 0200 Well Crnrsrror6an_Star tatds and Hurt a
7.Is this a repair to as existing well: oyes or No t'e?)7p of fhir rf{nnl hay In rn prtrrlth:'A to the styli mpn�r,
ffthis it a telmir,fill mo:knolm well etwolow-d n-infoewwrifal itnfl r.tPlaln rile nrltare of file
rrlmir tert9rt8?I rrmnrkr.crttion nr un fLc hrxk nj'thi.c jonn. 23.Site d141ranl or additional well details:
You may-Use else back of this page'to provide additional well site details or well
8.Number of wells constructed: 1 cons(ruction de(ai Is. You inay also attach additional pages if necessan'.
For mn8lpir ioJe erhm of oevt-warer sttpAi v bells OX11'+t')th do-sor"r cominsetion,ymf con
.submitmir finrn. SURNIMA -�STUCTIONS
9.Total well depth below land surface: 15 (ft.) 24a. For All Wells: Subnut this form within 30 days of completion of well
Formaltiplewd-lis list 470(lepthsljrli Brent(e•.rmnpfe•-,:t6':(wowl20l(m)) construction toIlicfolto%ing-
10.Static water level below top of casing: 8 (ft.) Division of Water Remoorres,Information Processing Unit.
1f owee lawsl is ahm'r casing.lids^�" 1617 Mail Service Center,Raleigh.NC 27699-1617
11.Borehole diameter-8.25" (in,) 24b.For III Jallon Wellc ONLY: '•;.in addition to sending the form to the address in
24a abm°e. also submit a copy of this form within 3,0 days of conipletiott of well
12.Well construction method' AUGERS construction to the following:
(i.e.and r.rotary:cable.directpish ctc.)
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUTPLY WBLIS ONLY: 1636 Mail Service Center.Raleigh.NC 276994636
24r For Water Supple'&Injection Wells:
13a.Yield(gpm) (Method of tint:
Also submit one cop)' of this fora) w•ithiu 30 days ofcouipletioeof
13b.Disinfatiun type _ _ _ ___ Amount:-� _.-. well construction to the county tenth dcpndn=it of the comnty.where
constnicicd. I
Fonn GW-1 !Fart Carolina Dcpanntent of Em'irotutcrit and Natural Resources-Division of\Yates R6ouxl_ Rcviscd August`2013