GW1-2023-01891_Well Construction - GW1_20230222

i
WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Lewis LeFever F4,WATERZONES
FROM TO DESCRIPTION
Well Contractor Name 25 ft. 30 ft. Wet
2480 ft. ft. I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. I i Iin.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 It- 20 ft. 0.010 in• sch40 PVC
List all applicable well permits(i.e.County.State,Variance.h jection,etc.) ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Publie 20 it. 30 ft- 2 in. .010 SCh40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT h1ETHOD&AMOUNT
❑Irri ation 0 ft' 15 ft• Portland Cem Pour
Non-Water Supply Well:
OMonitoling ❑Recovery 15 ft' 18 ft Bentonite Chil Pour
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
18 ft 30 ft #1 Sand Pour
❑Aquifer Test ❑StolTnwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/mck type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
12/28/22 MW27 D ft. ft. : -> >. lam'
4.Date Well(s)Completed: Well.ID# N d�
5a.Well Location: ~ �0
Highland Lumber Comp Inc.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. rtnr ►.ts
310 Blount Street, Fayetteville ft. ft. I v�`QU°`' :V
Physical Address,City,and Zip 21.REMARKS
Cumberland 0437-42-6300 Bottom Cap,J Plug,8"FMC
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(if well field,one lat/long is sufficient)
35.04748 N -78.88505 W
-SidatureofCertifiedWLVI Contractor b Date
6.Is(are)the well(s): RIPermanent or ❑Temporary By signing this farm,i hereby certify that the well(s)it-as(n•ere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 lYell Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to i the well owner.
!/this is a repaitl.fll out known well construction information and explain the nature of the
repair under#21 remarks section at-on the back ofthis 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,vat can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 -(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
!f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.4 (in.) 24b. For infection Wells ONLY:I In addition to sending the form to the address in
HSA/DT-22 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method 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. I
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water RCSotlrces Revised August 2013