_Well Construction - GW1_20230327 (17)

Pnnt Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: j
I
1.Well Contractor Information:
JeffreyGrant
14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
35 It 38 ft.
4328-B �
rL ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a licable)
JG Drilling,LLC FROM TO DIAMETER' THICKNESS MATERIAL
ft. ft. in.
Company Name
WM0601250 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 ft- 34 ft. 1.5 1°' .25 Steel
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FR bM REE TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural Municipal/Public 34 ft- 38 ft 75 i° 1 .006 .25 SS
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft- None
x Monitoring ®Recovery ft. ft.
Injection Well: - - -- _ ft. ft.
Aquifer Recharge (Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery rl Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft. None
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,soilfrockt e, rain size,etc.)
ft. ft. Soil samples were not collected.
4.Date Well(s)Completed:3-14-23 Well ID#GW-1 ft. ft.
5a.Well Location: ft. ft.
ft. ft. ; 1
Facility/Owner Name Facility 1139(if applicable) ft. ft. -
4800 Murchinson Road, Fayetteville, 28311 ft. ft. MAR G
Physical Address,City,and Zip ft. ft.
Cumberland 0429-33-2447 2LREMARKS kIIy4'"'
County Parcel Identification No.(PIN) Temporwy we!'.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
35.105977 N 78.921841 W 2 2 e�f�Y!���- 1
3-16-23
6.Is(are)the well(s)oPermanent or ElTemporary S' nature of Certt ed ell Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
(this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under R21 remarks section or on the back of this fonn.
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 site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:One SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 38 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing:35 (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: 1.5 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Direct Push above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.anger,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 SuuDly& Injection Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to i a county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources � Revised 2-22-2016