GW1-2022-10508_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Justin Radford WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft ft
3270 A ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased veells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ft ft. in.
Company Name 16.'INNER CASING,ORTUBING `0thermalclosed400
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft 4•5 ft" 2" in. sch 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 4.5 ft' 9.5 ft 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUTa
FROM TO MATERUL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft 2.5 ft Grout Pour
Non-Water Supply Well:
2•5 ft 3.5 ft Bentonite Pour
2Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Cif applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
3.5 ft 9.5 ft Sand Pour
❑Aquifer Test ElStormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
120.DRILLING LOG:attach additionaLsheets if necessary) _
❑Geothermal(Closed Loop) ❑Tracer ]FROM TO DESCRIPTION color,hardness,soiVrock type etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 1 ft Brown fine sand
4.Date Well(s)Completed: 11/01/2022Well ID#MW-2 1 ft 3 ft Orange sandy clay
3 ft 10 ft Tan medium sand
5a.Well Location: ft ft .f.�•7,F r
TForce Project Flash n/a ft ft � a
Facility/Owner Name Facility ID#(if applicable)
ft. ft 2022
531 S Eastern Blvd, Fayetteville, NC ft ft
Physical Address,City,and Zip 21.REMARKS
Cumberland 0436-98-8492 c
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cer' cation:
(if well field,one laUlong is sufficient)
I'
35.036919 N 78.866624 W
Signa of Certified We Contrac r Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby ceritfy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 9.5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dijjerent(example-3 200'and 2@100) construction to the following:
10.Static water level below top of casing: n/a (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter• 6 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Hand auryer 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Hand construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013