GW1--03246_Well Construction - GW1_20230511

• 'WELL CONS'CRUCTION RECORD Far Hernal Use ONLY;
This form can be used far single or multiple wells
I.Wdi.Ct iitractoc Information: 1
41..A AT'LRZONES . . • . .
Brian Ewing FROM 'TO DF$4.iIPTlON
WelI Corartclor 14:nn4. ft. ft. I .
4240-B R. R.
NC Well Conlraclar Certification Thurbert&:0UTER CASING deim4tl=rised-oc115).OR LINER till.d :atable):. . . _ .
moat To - DIAMETER TITICKNESS a MATERIAL
SAEDACCO Inc 0 ft, 10 (l. 1" in. SCH-40 PVC •
(.ant]r;uq•Naptc. , T.MANNER CASING OR TQItBtNG:( iibeiruui cttrsed-milli.; . _
FROM TO . DIAMETER. TIIIWKNESS MIATERIAL
2.Weitt Construction Penult*: It, It. ut.
lilt all applicable v,.ellpeneits(i.e.County..)-(file,Varimrrr,lrydC7i co.('rr.) ft. It. in
3.'Wcll Use(eller!:well use): - '17.SCREEN . -- _ - -
Water Supply VeI1:' EtiOM TO ttrAMRTER sr.(ITsin Ttti(;KSI s MMArrnr.sr,
0Agricultural 0.Mti]iicipaliPubhic . •
10 ft. 20 R. 1." In oi0 sex-4o PVC
I Geothemat(Ideating/Cooling'Supply) DResiidentiai•WaterSupply(single) (t. rt. in,
©ludustriaUContntcrcial DRcidential linter Supply(slurred) 't8:GROUT - I
FROa1 TO. .IiATERLaL EMPL10E7IENTalE11110D&A110LINT I
Olrrigation 'ft ft.
Notl4.Ite'rSupplyWell: h. tt. • . .
RIMt nitarini; I:Recovery
Injection Well: ft.• ft.
D aquifer Recharge G7Gronndaatcr Rciucdialion .t9:SAND1(7{AVEL t•ACK alulii licbt:t' .. - - : -
-FROMTO alATKRrAI. RUPi. CMIENt merino]
❑AgnifcrStoragc and Rccm'i n' .DSalinity flamed 8 It. 20 tt. FILTER SAND # 2
❑Aquifer Test DStornisTatcr nrtina a rt.. ft,
°Exp rimental Toz.hnology DSlihsidcnec C4ltiml '
tn.DRILLING LOG7altach addltiiniatgheets ifiteeessnn'1
OGeoiltenilal(Closed Loop) DTraeer ROM To • Dri5CRtvTION(color.It 111,01,xiiVnIC;tr1A..Vsinarcaim)
❑Cre+othennal(Heatine/Cuolillg Retur) DOther(explain under.l2I Retuaths) 0 At. 10 ft. FILL SILT AND SAND
• 10 ft. 20 ft. WET SAND CLAY
4.Date Weli(s)Completed: 4-3-23. Welt int/PI-PZ-1 „
ft. rL ��- j a,x g ���!—}}}y,,,
54.Well Location: .ft. ft. , ., „,i+ 4'
Allison Pini ft. ft. ®MAY i 1 20Z3
Facil€tyAttr o:rNamc Facility Mk(ifappli:able)
405 Jax Ct., Fayetteville, NC, 28312 ft. ft. lnfcr�;` rC+7�t,s ;it 1!tt
Physical Address_Cit..and Zi tea• '"�' •
l. S P 3 L.REM11.tRI{S' . . ,
Cumberland PIEZOMETER INSTALLED. BENTONITE SEAL 6 TO
Comity Parcel hici tiftcatlnu No,(PINT ' 8'
5h..i.:ttitudc'and l.ongituitc in degrees/minutes/secondsoi'deeintal degrees; 12,Certification:
(if u cif fxid,Ogal;ti.Tgugi;iodtiCktd) '
N '1V Brian Ewing.. 4/12/2023
Signature.afCcrtificd Well Contrrctoi Dale
6.Is(ore)the R'el!(s): 17Plotllattettt or SITeul1(orar}' try 5'i$nhrj Mix_Oita..1 hereby cerrifv thni the❑vdiiay nn (Hyrrej aor4Inwted ar.aatorthrn
ce
ri.(i 154,YGtC 02C,010,9 fir 1 SA NCAC 02C,0200 N i ll ConsNaction Starukrrds and rhar a
7.Is this a repair to an eiisting went °Yes or XNtl 'reirs.of rhi.,rerorri hhs bean prnrided di the well choler,
if thls:it ft-i.i r,fill f(tr krtouw WO rvtra,tnrrtlafi irfilreuuion rttt;l t tplain the norms of the
(*lair o der 021-rOmocks secirun or at the bark-of this form. 23:Site diagram or additiouat,well detaits:
You may use the back of this page•to provide additional well she details.or Well
8.Number of wells contracted: 1 construction details. You inac'also albeit additional Pages if necessary.
For trudripTe!njecrhan or arum-natter supply welds ONLY mirk the armor corrs(rirrriar,you can
sukmir one farm. $CTBh1iTTAL iNSTUCTiONS
9.Total welt depth below hind surface; 20 (('t•) 244 Fur All Wells: Submit this form within 311 days of completion of well
For innlriplc icells—&t rdl depths ifdiffart•nt lexarnpie•-3@?,Pf'an 1.263. D) construction to the foltolsingg:
10.Static.Inter kr-rel below top of casing: 040 Iliris°tun of Witer Resources,Information Processing Uilit,
if natter lcvrl Is idiom!t'ciusitt;.itv"t" £617 hlait.Service Center,Raleigh,NC 27699-1617
It,Borehole diameter,2.25" (in.) 24b.For Injection'kVetls ONLY: In addition to sending the Cann to the address hi
24aabove. also submit a copy of this form within 30 days-of completion of well
12.Well construction method:DRIVEN - cottsti melba to the following -
(i.e.anger.rc(ary,cable,direct push.ate.) '
. Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27659-1636
f3, Field Method of test:
14e._For Water Supply'&Injection.Wells:
4 (g(InI) Also submit one'copy of this Than Within'30 days of completion of
13b.Disinfection hoe: Amount: well construction to the county health department of We coilnty where
constructed.
; j
Funs GW.1 Nonh Carolina fxpaamein of EE)t•mnunenr and Natural Resources-Division of Wailer Rantrca Revised August ND