GW1-2021-00091_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
David E. Meyer 14.-ATER`ZONES
Well Contractor Name FROM TO DESCRIPTION
2527-A 3 ft- 12.5 ft- surficial aquifer
f. ft. i
NC Well Contractor Certification Number 15.'OUTER CASiNGOor multi-case&wells OR LINER ifa Iicable
Protocol Sampling Service, Inc FROM TO DIAMETERl.
THICKNESS MATERIAL
Company Name
0.3 ft- 2.5 ft- 2 1 in SCh.40 JPVC
16:INNER CASING OR TUBING: eothermat closed=ioo
2.Well Construction Permit#• na FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: =17..SCREENFROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑MunicipaUPublic 2 5 ft' 12.5 ft' 2 'In' 0.010 SCh.40 PVC
❑Geothenal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft 2•5 ft. in
❑Industrial/Commeruial ❑Residential Water Supply(shared)
01ni ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT-
Non-Water Supply Well: 0.0 ft- 1.0 ft- concretetoement gravity pour
IJMonitoring ❑Recovery 1.0 ft- 2.0 ft- Bentonite gravity pour
injection Well: ft. fa
[]Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK(if a licable -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL 11JAMPLACEMENTRETROD
❑Aquifer Test ❑StormwaterDrainage 2.0 ft' 12.5 ft' #3 quartz sand
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.'DRILLiNG LOG'attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(ex lain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock tym grain size•etc
0.0 ft- 1.0 ft- Dark gray clayey sand (SC)
4.Date Well(s)Completed: Oct.4, 2021 well iD# MW-3 1.0 ft- 3.0 ft- Light gray clayey sand (SC)
5a.Well Location: 3.0 fL 5.0 It- Reddish yellow&Gray clayey sand(SC)
Consolidated Coin Caterers na 2.0 ft- 13.0 ft- Gray&White sandy clay(CL)
Facility/Owner Name Facility ID#(if applicable) ft. ft.
12641 North Rocky Ford Road Laurinburg NC ft. ft.
Physical Address,City,and Zip ft. ft. N0702
Scotland 010247 01 01 4 _21.REMARKS: _ eecr���r�n,� '
County Well screen set high due to high seasonal high wateM errla6r 406oraed previously.
tY Parcel Identification No.(PIN)
'
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: David i t h '
MUUMINU OF
(if well field,one lat/long is sufficient) 22.Certification:
34°44' 56.81" N 790 24' 15.86" W �"_ 10/5/2021
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this ftnn,I Hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out brown well construction information and explain the nature of*1he ol'this record has been provided to the well owner.
repair under#21 remarks section or on the back of this 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).;You may also attach additional pages if necessary.
dulled. 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12.5 (fG)
For nutltiple wells list all depths ifdifferent(example-3Q200'and 2ca 100') Submit this GW-1 within 30 days!of well completion per the following:
10.Static water level below top of casing: 7.00 (ft) 24a. For All Wells: Original 'form to Division of Water Resources (DWR),
Ifwater level is above casing,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8 24b.For injection Wells:Copy to DWR,Underground Injection Control(IUC)
LI�+ ('a) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: HSA
24c.For Water Supply and Oven 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
Pennit Program,1611 C,Rai eig , C 276 -1 11
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Denartment of Envirnnmental Onality-nivkinn of Water R®.. nr ea o-.,:.-a e_s;_7m R