GW1-2022-06222_Well Construction - GW1_20220620

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
David E. Meyer 14..WATEWZONE3
Well Contractor Name FROM TO I DESCRIPTION
2527-A 12.5 ft- 18.0 ft- fine sand
NC Well Contractor Certification Number fr. tr.
15.OUTER.CASING for multi-cased-wells),OR LINER'if a`licable)..: _.
Protocol Sampling Service, Inc. FROM - TO DIAMETER I THICKNESS MATERIAL
Company Name
-0.3 ft- 8 ft- 2 in. Sch.40 PVC
16.INNER:.CASING�OR TUBING eothermal closed=lao .
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable uvll construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 11 SCREEN :" -_
FROM TO DIAMETER SLOT Sl%E THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public 8 ft. 18 ft. 2 In 0.010 Sch.40 JPVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 8 ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft, 4.0 ft• Portland pour
InMonitoring ❑Recovery 4.0 ft- 6.0 fr. Bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 6 ft- 18 ft #2 quartz sand pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LUG attach additional sheets ifnecessa.
yy-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soi0rock a rain siu,etc.
0 ft. 2 ft- Reddish yellow silty fine sand (SM)
4.Date Well(s)Completed: May 26,2022 Well ID# M V -3 2 ft' 6 ft- Gray sandy clay(SC)
5a.Well Location: 6 ft' 7 ft- Gray silty fine sand (SM)
Former Merita Bakery na 7 ft- 10 ft- Black fine sandy clay(CL)
Facility/Owner Name ft. ft.
Facility 10 13 Lt brownish gray clay(CL)
601 Ramsey Street Fayetteville, NC 28306 13 ft- 15 ft- Gray clayey fine sand/sandy clay(SC/CL)
Physical Address,City,and Zip 15 ft. 18 fL Gray silty fine sand (SM)
Cumberland 0437-67-4705 ILREMARKs =
County Parcel Identification No.(PIN)
�- rW
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (� )
(if well field,one lot/long is sufficient) !TML JUN 9 0 ZQZz
35.062605 N 78.878625 �,, � a 5/26/2022
6.Is(are)the well(s): [!)Permanent or []Temporary Signature of Certified Well ontracloi... O� to
By signing thisfornt,l hereby certify that(lie well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L'INo 15A NCAC 01C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair-under#21 remark section or on the back of this fornn.
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'Sce Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 18.0 (ft.)
For multiple wells list all depths ifdierent(example-3@200'and 1@1001 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 12.80 (ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+^ ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.6 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: auger
24c.For Water Supply and Open-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(gpm) Method of test: over 100,000 GPD: Copy to DWR,CCPCUA
13a.Yield Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018