GW1-2023-00105_Well Construction - GW1_20230110

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NORTH CAROLINA
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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
G W 1-2023-00105
Are you submitting a scanned form?* Yes
No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
John Shelley [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
2097 A JOHN SHELLEY SHELLEY PUMP&WELL SERVICE
2.Well Construction Permit#:
W ELL-2021-00080
List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County,
etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Water Supply Well* Geothermal (Heating/Cooling Supply) Industrial/Commercial
Irrigation Municipal/Public/Community
Residential Water Supply(single) Residential Water Supply(shared)
Wells> 100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield

12/12/2022 10
(gallons per minute)"
5.Well Location
Facility/Owner Name*
Jacob Zamora Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Cumberland
Physical Address* Street Address
3280 Sunny Dale Drive
Address Line 2
City State/Province/Region
Fayetteville North Carolina
Postal/Zip Code Country
28312 Cumberland
Latitude* 34.9181060000 Longitude*78.7883150000
Decimal degrees Decimal degrees
........ ................ ......... ........................... ........................... ......... ......... ......... ...................
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes • No
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.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
39 surface?
For multiple wells list all depths if different 34
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
17 6
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
10 13a.Method of test:
If applicable air
13b. Disinfection type:* 13b.Amount:
Hth 1.5 cups

14.WATER BEARING/FRACTURE ZONES
From To Description
30 39 Tan sand
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
1.00 34.00 2.00 Sch40 PVC
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
34.00 39.00 2.00 Sch40 PVC
in feet in feet in inches
18.GROUT
..................................
From To Material Emplacment Method&Amount
0.00 20.00 hole plug pour
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
32.00 39.00 pea garvel pour
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
2.00 16.00 Red sand
in feet in feet
16.00 30.00 fine white sand
in feet in feet
30.00 39.00 tan coarse sand
in feet in feet
21. Remarks
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
.................
* By signing this form, I hereby certify 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 copy of this record has been provided to the well owner.

23.Certification
Signature of Certified Well Contractor