GW1--03245_Well Construction - GW1_20230511

'WELL CONSTRUCTION.RECORD
Far Internal Usc ONLY: i
' vais farm can be used far single or intdtipk wells•
1.Well.Colitractor Inforuation:
t1 WA-rEEaZONES • • • - .
Brian Ewinq FtaO%1 iU DrSCItIPTION
Well Coeur etor Name R. ft.
4240—B R. It.
NCRe l CorauactorCcnifir�tianNiunc�r -tS::Ot1TER CASING(fur Midi Veti eirn-dfisy OR LINER'(ifap'licablel. ._ .
FROST , ! To • DIAMETER TFnCF:NRSS MATEAtAL
SAEDACCO Inc 0 ft. 10 (L• 1" in.• . SCR-40 PVC.
(.'0110:un•h'autc. 16 INNER.CASING OR•TQBING thi";rihiilitaI'cW+r:d.loiij) •. • •
FROM TO_ ' DIAMETER THICKNESS MATERIAL
2.'VYe1I Construction Permit#: . R. ft, in. .
List di amilird!.,Wrlperrw>s(i.c.County.State,Variance.Preen r4 rs-.J
R. ft, tn.
3.Well[Sse(cheek.\yell nisc): .
I7:SG:RElN
•
`VaterSupply Well: •
-_: FR051 r TO MAMMA Sr.OT5i7.E vibe Nle(S I tr,aria-nat.
CIAgncultaital DMtitiicip:lll'Public 10 it. 20 R. 1" in O10 SCH-40 PVC
°Geothermal(HeatinglCoolitr3 r Supply} DResidential.WateSupply(single) 6. ft in
DludustrialiContorercial °Residential Water.Supply(slurred) •to GR011T i _' I
PROM TO. MATERIAL I EMPLACEMENT METHOD.A AMOINi'
Olrrir'ntlon . . . . . .fL ft..
Non-Vater Supply Weil:
ft, ft,
SdMtinitoring . DRccovery ,
injection Well: • ft. ft. .
°Aquifer Recharge OCitontidrtster Rciitcdiation ,19:SANDIGRAVEL PACK tirtlrpuear,ttV •. • . . - -- .
-B'ROSI TO SLlrt:RIAL. EMPLACEMENT SrrTtiOu -
DAgnifcr Storage and Rceeveiy El Salinity Hamer' 8 R. 20 IL FILTER SAND # 2
❑Arltrifer Test ❑Stornict atcr!Drainage
DErperinicntitl Te Broke DSitbsidence.Cotdml h. . . . .
4�20:DRFLLCNG'LOG'fatlidiadilitiirnal slireIs'ifitccessan•1•
OGesiltetal(Cluset[Luupl 'OTrdcer • FROM . d TO ' DESCRIPTION(oobr.htirdncti,xoIA'rnv4nisc.men srrt,dm
DGr otlteimal(Hcatine Cuolitlg Return? DOther(explain under Ik2I Remarks) 0 .It. 10 ft. FILL SILT AND SAND t
10 ft. ! 20 fL WET SAND CLAY , ..
'.DateWetl(s).Canrpieted: 4-3-23 WeltiD#DA—PZ—i Fes' �` 4' -
• fL . ft, ri. ...i i V 1..-
5a,Well Location: .ft. ft. MAY 1 1 9023
Patsy Davis ft.. ft,•
FactlityJKIwticrNauoc ' Facility IPt(irappliabls) R. ft. l g{,; u� f C""" '
y'�'ir
7242 Fire ,Department Rd„ Fayetteville, NC, 28348 ft. ft.
Plgsichl Address_City..iind Zip 21:REM1f v[tAS .
Cumberland PIEZOMETER INSTALLED. BENTONITE SEAL 6 TO
County 1'atccl ltleadifleation No,(f iNt 8'
56,.I.iatitudc and Longitude in degtt.•cs/minutes/seconds 01'decimal degrees: 22.Certification:- -
fthaeit fCtd,oat lat1OUhi%•srdtici::id)
d
IC ��! Brian E ofl ' 4/12/2023
Sign3turafCcititiiedWell Contractor• �R g Date
6.Is(are)the•w'ell(s): I:Permanent. or S]Temporary , !ly Aignbrl gar him,.1 hereby c•errejv rhw MN rr'edhiii mu(MrreJ etrr4irnc'red hr...r iY•ojthrnc
Oult 15.4 NCAC 02C.(100 or Mt NOW o2C,0200 MU C'oastiirrrittn Standards and silos
7,Lc this a renaicto an ceistin„well: Oyes air No OW.o'frlw-rPlordJhi ss lima provided roJ1.sir II rimier.po)r .
(f th(s:1%a rs ,fill e�ur kraoirit wolf cs!ua!r cthira trfctrorrarlo (Mi
l rl to t1t(ahr the nttnare oftIic
relmir wafer d21'remarks'Milian arion the bail of this forme. 23.Site dlai run or additional welt detnits:
Yon may use the back of this page to provide additional well site details:or Well
8.Nemrller of welly constructed: 1 constluetloet details. You May aLo'atlaclt additional pages if iictessaty.
For malrlple Ii*eilon err non-usurer saippJy u't?h ONLY it Wi rhe.sirrne cotrstrtrrtiatr,you on
submit one form. SLiBM ITTAL iNSTUCTIONS
9.Total Welt depth beteiw-Iand surface: • 20 (ft,) 241.For Ali Wells Submit this farm within 311 days of comptctioti of well
For rntrlsiplc:cells liar all depths ird.fferenr(example-30200'and.2 Gat 1017) constniction topic following:
M.Static water level below top of easing: . (ft.) Divisiuu of Waiter Resources,Information Processing Unit,
/firer hv.1 J.I above casia;;,bst'^+" [G17 Mail Service Center,Raleigh,NC 2 7 699-16 17
11.Borehole diameter:2.25" . '(in.) 24b.For I)iketign Welts ONLY: in addition tosending the form to the address in
24a above. also submit a copy of this form within 39 days-of completion of well
12.Well oonsatwction method:DRIVEN construction to the follow ire:
(i.e.odour,rrAu,l',cubic;diner push.c(c:J Division of Water Resource's,Unde►ground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
IJ;a Yidd(},rlinl) Method of test: 24c.For Water St pply Si Injection Wells:
Also submit'one copy of this Irma within 34).days of completion of
1Jb.Disinfection typo Amount: -well canstrnctian to the county health department of tire coiinh•where
• constructed.
Farm GW-1 Nonit Carolina Ik someat of Encimrurvit and Natural Resources-Division of Water R tatrom Revised August 1013