GW1--03248_Well Construction - GW1_20230511

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•WELL CONSTRUCTION RECORD For[menial Usc ONLY:
This form can lx usv4 for single or multiple wells'
1.IfVcll.Ct ntrltctorIttfornlation: •
.
. ''LLAVATERLQNIrS . • - ' i .'. .
Brian Ewing FROM TO i nmiCtt PITON
Well Cori alor Tame ft. ft, I
ft. ft.
4240-B
•NC�Vc11ConttadorCcnifi�rtionNurrklcr ?15::OtlTER CASING(fur'innI case4nifIs ORLiNER(lteti Noble), .;_ '. ..
FROM 'i TO DIAMETER TRIMNESS MATERIAL
SAEDACCO Inc 0 fL. 5 ft. •2" in. SCH-40 PVC
('on(p;uq-tropic. toV1NNER'CASING OR TI)HING.teiixithcrma_t ekned-lo ttirz__ ,--: • ' '
FROM TO DIAMETER TUICKNF.SS • MATERIAL
2.We'll Constr"uctirin Permit#: _ R. ft. 'hi. '
List u.0 c}pilicnfile wellprsnr¢s(ix.C.auits.State,.Varionre,fr}rectic4 eft)
-ft. ft. in.
3,'', cfl iisc(citecl.ce'cft use! 17:SCREEN .
Water Supply Well: FROM TO DIAMETER SLOTSTO: TRICHNESS I SIATRRrAI,
0Agtteultural CliAtinicipaUPnillic 5 ft. 15 It. 2" in. 010. SCH-90 PVC
ClGeothemial(HeatingiCaoting.Supply) DResiidential Water Supply(single) ft. .rt. is
ClindustrialIConmtercial • DResidential Water Supph'(sleeted) :tt7:GROUT
FROM TO. MATERIAL i EMPLACE'MENThiEirIODSA.110UNT
0hritmtion• . . . 0 ft. 3 ft, PORTLAND • 'TREMI
Ntum:Water Supply Welt: ..
D?ifenitoring pltccm'cry' . , , ft.'
ltiJectlint Well: ft. ft .
I7AquifcrRecharge DGtouridtiatcrRenicdiation 49:sANDIGIL1VEfi:t'ACKiiif:ntryrlicahttlr : - - - --=-.
T FRO51 10 al& AIML R5IPI.Aciett:NTNI Ellina
DAgaifcr Storage aid Rceoe04' [!Salinity larliar. 4 ft. 15 ft. FILTER SAND tl 2
. 17 Aquifer Test. DStorimt;itcrDrrinage i • ft. R• .
Ohylerinuntnl TeChnolog' lJSithsidence.Coldrol •
'B(t.;DRILLll(1G'1.oG"(attaeri.additiiroal Sheets':if ucecsvaivi-
ClGeotltennal(ClosedLoop) ElTracer FROM TO DESCRIPTION hnur.main.,+,vjlunicl,tytx:ikonsin.de1
DGeotiteinial(HeatiugCooling Ream) DOther(espleitt under 421 Remarks) 0 .ft. 10 ft. FILL SILT SAND
10 ft: 15 fL. SILTY SAND MOIST TO WET
-I.Date Welts)Coalplcicd:'474-23 • Well tiDffMW-AM-2-S-1
• ft. ft..
5a,Well Location: .ft ft.
Francis Minshew it,- it, +''`� 'S �"�
FaciTity.OwtierNalve Facility ii)k(ifappiiablc) A�—ELF —�S '
ft. ft.
4301 Munsey Rd., Fayetteville, NC, 28306 . ft. ft.
Plgsi:.id Address;Cite'.and Zip .:21 RE41Aiiics. .
BENTONITE SEAL 3 TO 4'; �tl r"1'.`'�`"�"" '
Cumberland 1ti�Giix;":�' .>♦fir'"`
Comity load ldentifieaiionNo:(PIN)
t
56.I.ittitildc land E.ringlttsde in t egre slminutes/sccouds or deciriial degrees: 22;Cerriticatiritt• •
(if hell ItOld,ois1 la(i1orig is sidliti,:nl)
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' N Rr B,rianEsf 4/12/2023
Signature Of Certified Well rantfaClar - Date
6.is'(are)the'APell(s); XlPcrrnanettt or DTeutporary itr signing this foirtr,.1 hereby certify char Ilex wd!4st r:us(isrtr.J ini red Jrr.as.orfkifer
with 154 NCtC 02C.01(10 as l;A NCrtC 02C_,t1200 Well Cinistrn.tinn Standards and slurs
7.Is this a repair to an existing well: DVcti or BINo Cop of this rei-aril has been(itri ided to:Me sir!/r;,riii•r,
if thtls:Js 0 rtlxrJr,fill oat 4r1O1i7J Well 030.011(Cli0 i itrjrlrioerion and esp(aln to near'of OM
repair corder C2i'retnar10 sceuttn ar Asa rim bac:4 oftlds form. 23:Sitediagrani or additiureal well dedaibn
• You may,use the back of this page to pro%ide.tddilioua)well site details'of Well •
S.Number of Wells must nutted: 1 cousuuctioti details. You May itlso attach additional pages if iteecessaty.
Rif tnuhlpleLtjeerhaiorrrrut-watersupply itdls ONLY with rlic.sinaeerrrrstrurfwtyruCOO
sairmir one form. SUBMITTAL iNSTtiCTIONS '
r1.'II'ot.tl Well depth below land shrine& 15 . (ff.) 24a. For An Wells: Submit this form within 30 days of completion of well
For iuuhiple i:•elk:'ist Ali depths ifdl ,rent(ovantp(e-3@200'and.2e10r)y constniction to the following:
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1(1.Static water level below top of eusingi' ((b) Division of Water Resnue es,!affirmation Processing Unit,
I/water lave!Is ithoi'c easing,rue"+" 1617 Diail.SerTice entcr,•Raleigh,NC 27699-1617
11.Borehole diameteti.8.25" . (in) • 2-I11;For{3ijcetimm W'th ONLY: in-addition to-sending tit:form to the address in
240above._also submit a copy of this foto, within 10 days-of completion of well
12.Well consintetion method:AUGER cousttuctioti todlte follow ingi
(Lo.auger.rotary,cable.direct tusk.etc.)
Dle'isiot'of Water Resource's,Underground Injection Coutrol_Program,
FOR WATER SUPPLY WELLS ONLY, 1636 Mail Service,Center,Raleigh,NC 27699.1636
t3;>k `icld'(k�ia11 \Icthgdoftest 21e.For WaterSuylply,&In_jection'.Wells:
Also submit one'copy of this Rini:within•30 days of cotupletioit of
• 13h:Disinfection type: - Amount: well conMtnutian to the county health department of the county where
constn etcd,
Fain GLV-1 Monti Corolliu Department of Environment and Nation Resources-Division of Water RlEotrcin Revised August 26l3