GW1-2021-00090_Well Construction - GW1_20211109

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
David E. Meyer 14.WATER'ZONEs i
Well Contractor Name FROM TO I DESCRIPTION
2527-A 3 ft. 12.5 ft• surficial aquifer
ft. ft.
NC Well Contractor Certification Number 15;.OUTER CASING for multi-cased wells.OR LINER:)fa `livable
Protocol Sampling Service, Inc FROM To DIAMETER THICKNESS MATERIAL
Company Name 0,3 ft. 2.5 ft. 2 in. sch.40 1PVC
16 INNER'CASING OR TUBING; eotherm all closed=loo _
2.Well Construction Permit#• na FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,Cohmty,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN; '
FROM TO DIAMETER ! SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 2.5 f- 12.5 ft- 2 'n• 0.010 Sch.40 JPVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft- 2.5 ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) F185GROUTeYz3
01ni ation ❑Wells>100,000 GPD FROM TO MATERIAL c EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 1.0 ft- concrete/cement gravity pour.
nMonitoring ❑Recovery 1.0 ft- 2.0 f- Bentonite gravity pour
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK fa livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL CEMENT METHOD
❑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 necessae
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soillrock WM grain size,etc.)
0.0 it- 1.0 fL Dark'gray clayey sand (SC)
4.Date Well(s)Completed: Oct. 4, 2021 well ID# M W-4 1.0 ft- 390 f- Light gray clayey sand (SC)
5a.Well Location: 3.0 f- 5.0 f- Reddish yellow&Gray clayey sand(SC)
Consolidated Coin Caterers na 2'0 f- 13.0 f- Gray,&White sandy clay(CL)
Facility/Owner Name Facility ID#(if applicable) ft. ft. 1: �\
12641 North Rocky Ford Road Laurinburg NC & ft. F-
Physical Address,City,and Zip ft. ft. Nov 9
Scotland 010247 01014 '-21.REMARKS s -
Conn Well screen set high due to high seasonal high water t v`' u,N ly.
County Parcel Identification No.(PIN) o
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: David E. dyer,'P.G.
(if well field,one lat(long is sufficient) 22.Cert'fication: f
34°44' 55.80" N 79°24' 16.62" W 5 10/5/2021
6.Is(are)the well(s): [@Permanent or ❑Temporary Signature of Ce tfied Well Con for Date
By signing this form,1 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 known well constnrction information and explain the nature ofthe gfthis record has been provided to the well owner.
repair under#21 remarks section or on the back of thisforni.
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-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: 12.5 (ft.) i
For multiple wells list all depths ifd different(example-3@200'and 2 t@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),
If water level is above casing,rise"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in) 24b.For Injection Wells:Copy,to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: HSA 24c.For Water Supp!x and Op In--Loo 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 roducin over 100,000 GPD:Copy to DWR,CCPCUA
Penntt Program,1 1 MSC,Raleigh,NC 2 699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:.
Form GW-1 North Carolina Denartment of Fnvimnmental Onality-Divkinn of Water Rrannrrrc