GW1-2023-02199_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098 L
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells DR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER' THICKNESS MATERIAL
ft. ft. in
Company Name
16.INNER CASING OR TUBING eother a[closed-loop)
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft 30.0 ft 2.0 tit' I SCH 40 PVC
3.Well Use(check well use): fr. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 30.0 rt, 40.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft 26.0 ft' PORTLANDBENTONITE SLURRY
INMonitoring ❑Recovery ft. ft.
Injection Well:
fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
'
❑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
❑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,soilh•ock type,gmin size,etc.
0.0 ft• 2.0 ft. BROWN SAND
4.Date WeII(S)Completed: 01/18/23 well ID# MW-6 2.0 ft. 25.0 ft. ORANGE SANDY CLAY
Sa.Well Location: 25.0 t' ORAN_GESAND ,,40.0 t' i
ONE HOUR CLEANERS rt. ft. ! t
Facility/Owner Name Facility lD#(if applicable) rt ft. 9�
1303 FORT BRAGG ROAD FAYETTEVILLE 28305 ft ft
Physical Address,City,and Zip ft. ft
CUMBERLAND 21.REMARKS a�
Comity Parcel Identification No.(PiN) BENTONITE SEAL-26.0-28.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 03' 28.30" N 780 54' 06.54" W �� �1 01/23/23
6.Is(are)the well(s)• MPermanent or []Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby terrify that the wells)was(mere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has beenprovided to the well owner.
repair under#21 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 i 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 ifd�erent(example-3Ca 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),
f mater level is abate casing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If
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
Permit Program,1611 MSC,Raleigh,NC'27699-161 I
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018