GW1-2023-01892_Well Construction - GW1_20230222

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WELL CONSTRUCTION RECORD For Internal use ONLY: ! I
This form can be used for single or multiple wells
1.Well Contractor Information:
Lewis LeFever 14.WATER ZONES t
FROM TO DESCRIPTION
Well Contactor Name 20 ft. 25 ft. I I Wet
2480 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-casid wells OR LINER if a licable)
FROM TO DIAMETER THiCKNF.SS MATF.RIAI.
Parratt-Wolff-, Inc. ft. 1;I I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: 0 ft. 115 ft. 0.010�', i" SCh40 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 ❑Municipal/Public 15 1` 25 ft. 2 i" .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 METHOD&AMOUNT
❑Irri ation 0 ft. 10 ft. Portland Cem Pour
Non-Water Supply Well:
10 rt. 13 ft- Bentonite Chid Pour
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ENIPLACEMENT31ETHOD
13 ft. 25 ft. #1 Sand Pour
❑Aquifer Test pStormwater Drainage
ft. ft.
❑Experimental Technology- ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color battlness,soil/mck type,grin size,etc.)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) ft. ft. [�'•� Iry f -�.;• ,t f�
12/27/22 M W26 D n. ft. ---� ° '��"�-`•�
4.Date Well(s)Completed: Well ID# i,
ft. ft. �. .' ... Z023.
5a.Well Location:
Highland Lumber Comp Inc.
t�sd�tu�Li
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
310 Blount Street, Fayetteville
Physical Address,City,and Zip 21.REMARKS
Cumberland 0437-42-6300 Bottom Cap,J Plug,8"FMC w/sonotube
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well Geld,one ha/long is sufficient) I
35.04766 N -78.88471 W ; a3
Si allure of Certified Well Jontdclor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this)bran,I hereby certi&that the well(s)was(were)constructed/in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 fYell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy ofthis record has been provided to the well owner.
1/this is a repair,fill out known well construction information and explain fire nature ojthe I
repair under#21 remarks section a•on the back of this farm. 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 rmthiple byeelion a•non-water supply wells ONLY with the same construction,roil call
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths f foFi ferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing 20 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•4 (in.) 24b.For Infection Wells ONLY- In addition to sending the form to the address in
HSA/DT-22 24a above, also submit a copy o0his form within 30 days of completion of well
12.Well construction method: construction to the following:
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(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 Watcr Resources Revised August 2013