GW1-2023-02198_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 3098 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased"wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER TIDCKNESS MATERIAL
ft. m in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable hell construction permits(t.e.UIC,County,State,Variance,etc.) 0.0 ft. 30.0 ft. 2.0 1 ' I SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS AIATER1AL
❑Agricultural ❑Municipal/Public 30.0 1t. 40.0 B' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 26.0 ft' PORTLANDBENTONITE SLURRY
15Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
El Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 28.0 ft. 40.0 ft• 20-40 FINE SILICA SAND
❑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 421 Remarks) FROM To DESCRIPTION color,hardness,soithmck type,grain size,etc.
0.0 ft• 2.0 ft• BROWN SAND
4.Date Well(s)Completed: 01/18/23 Well ID# MW-7 2.0 fr• 25.0 ft. ORANGE SANDY CLAY
5a.Well Location: 25.0 It' 40.0 ft. ORANGE SAND_' -,•-�
ONE HOUR CLEANERS ft. ft.
Facility/Owner Name Facility iD#(if applicable) ft. ft. MAR
r
1303 FORT BRAGG ROAD FAYETTEVILLE 28305 ft. ft.
Physical Address,City,and Zip ft. ft. ill'iti•ii,� +?C� :�iiy::.^:;•'] !�ii,i.
CUMBERLAND 2LREMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-26.0-28.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 03' 28.30" N 780 54' 06.54" W 01/23/23
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this•is a repair,fill out known we/l construction information and explain the nature of the ofthis record has been provided to the Ire//owner.
repair under 421 remarks section or on the back ofthis form.
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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40.0 (ft.)
For multiple wells list all depths•ifdii ferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
35 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+"
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Font GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018