GW1-2022-06226_Well Construction - GW1_20220620

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
David E. Meyer .14:.WATER'ZONES"
Well Contractor Name FROM TO DESCRIPTION
2527-A 10 ft- 14.0 ft• surficial aquifer
ft. ft.
NC Well Contractor Certification Number 4Sl9UTER CASING(for multi-cased;wells)OR LINER If ap ticable
Protocol Sampling Service, Inc. FROM I TO I DIAMETER I THICKNESS MATERIAL
Company Name
+2,0 ft. 9.0 ft. 12 in. I Sch.40 JPVC
_ -
16ANNEItCASING_OR TUBING• '6thermiil!closed,loopj
2.Well Construction Permit#• na FROM TO DIAMETER THICKNESS " MATERIAL
List all applicable null construction permits(i.e.UIC,County,State,Variance,etc.) tt. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17:SCREEN FROM TO DIAMETER SLOT SIZE. THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 9 f`' 14 f`- 2 in. 0.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft 9 ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.:GROUT
❑Itri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 6.0 ft. Portland pour
❑Monitoring ItRecovery 6.0 ft- 8.0 rt. Bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge _ � ndwater Remediation
❑Aquifer Storage a Rg+{ y t� y 19..SAND/GRAVEL PACK if i Riiabl),- :.
'SS - @ p� 4 It BarrlBf FROM TO MATERIAL EMPLACEMENT METHOD
'4 r„:.. err 7a•-T,
❑Aquifer Test ❑StormwaterDrainage 8 ft. 14 f`• #2 quartz sand 1pour
❑Experimental TeehnoldaN 0 ZMSubsidence Control ft. ft.
❑Geothermal(Closed Loop) T gI .10:DRILLING10G'attaeh'.additionahsheets ifnecessa '
FROM I TO DESCRIPTION color,hardness,soil/rock type.grain size,etc.
❑Geothermal(Heliftl��bi51`�Jg, _�� ❑Other(explain under#21 Remarks)
0 ft. 4 ft. Dark yellowish brown silty fine sand fill(SM)
4.Date Well(s)Completed: May 3,2022 well ID# RW-1 4 ft. 7 ft. Yellowish brown fine sand fill(SM)
5a.Well Location: 7 ft. 10 ft- Yelowish brown fine to medium sand(SM)
McKee Homes LLC na 10 ft- 14 ft- Dark greenish gray fine to medium sand(SM)
Facility/Owner Name Facility lD#(if applicable) 14 ft. ft. Indurated marl
109 Hay Street Fayetteville, NC 28301 ft. ft.
Physical Address,City,and Zip ft. ft.
Cumberland R04806-006-131-000 21.REMARKs
Count
Indurated marl layer found at-14'bls
y
y Parcel Identification No.(PIN)
petroleum odor evident in saturated soils
5b.Latitude and longitude
1 g ude In degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22. cation:
35.255 N 77.929297 w �N� 6/6/2022
6.ls(are)the well(s): In Permanent or ❑Temporary Signature ofCeriiried W I Contactor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No ISA NCAC 01C.0100 or 15A NCAC 02C.0100 Well Constriction Standards and that a copy
Ifthis 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 remarks section or on due 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 I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 14.0 (ft)
For multiple wells list all depths ifdfferent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 10.40 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,we^+•• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.5 (in,) 24b.For Injection,Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: auger
(i.e.auger,rotary, 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
Lary,cable,direct push,etc.) county environmental health department of the county where instal e
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018