GW1-2021-04172_Well Construction - GW1_20210827

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Todd MuenCh 14.WATER ZONES
FROM TO DESCRIPTION
Wei I Contractor Name 18 ft. 25 ft. Wet
3371 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mWti-cased wells OR LINER if applicable)
FROM TO DIAMETER THICKNESSr MATERIAL
Parratt-Wolff, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loci
FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft• 15 ft- 2 i" SCh40 PVC
List all applicable ire//perntils(l.e.C'ouniv.Stale, Variance,lnieclion.etc.) ft. I ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft. 25 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft. 10 ft. Soil Tremie
Non-Water Supply Well: _ _-
OMonitoring ❑Recover 10 ft- 13 ft Bentonite Chii Tremie
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
13 ft' 25 #1 Sand Tremie
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20,DRILLING LOG'attach additional sheets if necessa'
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardness,soil/rock type,gmin size,*etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 5 ft. 17 ft. Tan, moist,silts
4.Date Well(s)Completed: Well ID#
7-28-21 TW-1 17 ft 25 ft Wet,pinkish/tan medium sand
5a.Well Location:
McKee Homes, LLC
Facility/Owner Name Facility ID#(if applicable) ft. ft.
69 Brownstone Lane, Southern Pines 28387
ft. ft. � sSII'i13 bra
Physical Address,City,and Zip 'fir1
21.REMARKSLt
Moore 858100170478 Dv
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field.one tat/long is sufficient)
35.171161 N -79.397796 W.
Signature ot'Certit�ied ellY ell Contractor Date
6.Is(are)the well(s): ©Permanent or [OTemporary By,signing dus.1brm, 1 herebv certify that the well(s)was(here)constructed in accordance
frith 15A NC'AC 02C.0100 or 15A NCAC 02C.0200 Well Consiruction Standards and ihol a
7.Is this a repair to an existing well: ❑Yes or EINo copy ofiltis record has been provided to the hell owner.
#this is a repair,Jill out known well construction informaiton and explain the nature of the
repair under 21 remarks section or on the back q1 this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessan.
har multiple injection or non-water.supply we/is ONLY wish the same construction,you call
submit one lornc SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
hor mu/riple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 18 (ft.) Division of Water Resources,Information Processing Unit,
tf water here/tv abore casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b. For Injection Wells ONLY: :In addition to sending the form to the address in
? HSA �/ �S� 24a above. also submit a copy of this form'within 30 days of completion of well
12.Well construction metho construction to the following:
(i.e.auger,rotary,cable,direct push,etc)
Division of Water Resources,,underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
m 13a.Yield
(gp ) Method of test: 24c.For Water Supply&Injection Wells:
,
Also submit one copy of this form within 30 daysofcompletionof
13b.Disinfection type: Amount:
well construction [o the county health department of the county where
constructed.
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 201