GW1-2021-00074_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
David E. Meyer
14:WATER'ZONES,
Well Contractor Name FROM T I DESCRIPTION
2527-A 3 ft. 12.5 n surricial aquifer
NC Well Contractor Certification Number
I&OUTER CASING:formuld cased""ells'OR•LINER'if-a licable
Protocol Sampling Service, Inc FROM TO DIAMETER TNICKNEss MATERIAL
Company Name
0.3 It- 2.5 ft• 2 1 in sch.40 PVC
16.dNNER,CASING`OR-TUBING' af'cIdiied4aoDY
2.Well Construction Permit#: na FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cmmn,,Stare.Variance,etc.) ft. R. In.
3.Well Use(check well use): ft. A. In,
Water Supply Well: 17cSGREEN_.a
FROM TO DIAMETER SLOTSUE •THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 2.5 ft' 12.5 fL 2 In 0.010 sch.40 JPVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 2 5 ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 718.:GROUT: .,
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0•0 ft, 1.0 ft concreteleement gravity pour
CJMonitoring ❑Recovery 1.0 ft- 2.0 ft- Bentonite gravity pour
Injection Well: ft. n
❑Aquifer Recharge ❑Groundwater Remediation
19 SANDIGRAVEL PACK If a"licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 2.0 ft, 12.5 n• #3 quartz sand pour
❑Experimental Technology ❑Subsidence Control n. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRIEI, G=LOG ett th additi6naUsheets V nece"asa"`:
❑Geothermal Heating/Cooling Return) ❑Other(explain under#21 Remarks) I FROM To DESCRIPTION(color,hardnM solurock tym arain size,etc.)
0.0 fL 1.0 ft• Black silty sand (SM)
4.Date Well(s)Completed: Oct.4,2021 Well ID# MW-4R 1.0 ft- 3.0 m Yellowish red sandy clay(SC)
sa.Well Location: 3.0 ft- 10 n, Gray;elayey sand(SC)
Country Store & Feed na 10.0 fL 13.0 n- White clayey sand (SC)
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
7828 Deep Branch Road Pembroke, NC ft. ft.
Physical Address,City,and Zip ft. n.
Robeson 934302764527 2L REMARKS,.
County Parcel Identification No.(PIN) TMeweO"°mC°'°"sin8°1P"'"`°"'0dW1"h uBmhomsamho.,mmaa mo
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
David E.Meye
(if well field,one lat/long is sufficient) �"ftnOA sn r,. -
N W 22.Cer'fica<on 10/5/2021
34°39' 49.54" 79 11' 50.59" '�"
( ki
6.Is(are)the well(s): 231'ermanent or ❑Temporary Signature of Certified Well Coutm or Date
By signing this form,I herehv certifi,dint the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 1jA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out lanown 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 ofthis 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.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12.5 (ft.) i
For multiple wells list all depths iiralfferenr(erample-3 a200'and 2 g100') Submit this G W-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 7.50 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
I#'water 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)
u L+A (In.) Program,1636 MSC,Raleigh,N,C, 27699-1636
12.Well construction method: H SQ 24c.For Water Su 1 and O ell ILoo Geothermal Return Wells:Copy to the
(i.e,auger,rotary,cable,direct push,etc.) county environmental health department o the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: