GW1-2021-00093_Well Construction - GW1_20211109

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
David E. Meyer 14WATERZONES
Well Contractor Name FROM TO DESCRIPTION
2527-A 3 ft- 12.5 it- surficial aquifer
ft. ft.
i
NC Well Contractor Certification Number I&OUTER CASING (for r mold-cased'wells OR LINER•if a '6cable :'
Protocol Sampling Service, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0.3 ft' 2•5 ft' 2 in. Sch. 40 JPVC
16.INNER CASING OR TUBING: eothermal closed-too
2.Well Construction Permit#: na FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,Comity.State,Variance,etc.) ft. ft. in
3.Well Use(check well use): ft. ft. In.
17:SCREEN I
Water Supply Well: FROM I TO DIAMETER ! SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 2.5 ft 12.5 ft- 2 '"' 0.010 sch.40 PVC
❑Geothermal(Heating(Cooling Supply) ❑Residential Water Supply(single) ft- 12.5 ft i"'
❑Industrial/Commereial ❑Residential Water Supply(shared) 4 , -
18:(GROU, .L.%_ ..i,: :i_
❑hTi ation ❑We11S>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 1.0 ft- concrete/cement ' gravity pour
nMonitoring ❑Recovery 1.0 ft. 2.0 ft gentonite gravity pour
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19:SAND/GRAVEL PACK(if a `licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL HMO 1 CEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 2.0 ft- 12.5 ft- #3 quartz sand
❑Experimental Technology ❑Subsidence Control fa ft.
❑Geothermal(Closed Loop) ❑Tracer 20.,DRILLING'LOG attach additional sheets if necessa
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I FROM TO DESCRIPTION(color,hardness,soll/rock tyoe,Brains etc
0.0 ft. 1.0 fL Dark'gray clayey sand (SC)
4.Date Well(s)Completed: Oct. 4,2021 Well ID# MW-1 1.0 ft. 3.0 ft. Light!gray clayey sand (SC)
5a.Well Location: 3.0 ft. 5.0 ft Reddish yellow&Gray clayey sand(SC)
Consolidated Coin Caterers na 2•0 it. 13.0 ft• Gray&White sandy clay(CL)
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. PECERIED
12641 North Rocky Ford Road Laurinburg NC ft. ft.
Physical Address,City.and Zip ft. ft. Nev 9 a
Scotland 010247 01014 21.REMARKS tHt
Count Well screen set high due to hlgh seasonal high Ovate 8' nasty.
Y Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: David �.Meyer, P.G.
(if well field,one lat/long is sufficient) 22.Certification:
34°44' 56.22" N 79�24' 16.25" w �' 10/5/2021
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Montractor Date
By signingthisform,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
ifthis is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on dhe 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-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.)
For multiple wells list all depths ifdifferent(example-3 u@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: 7.00 (ft.) 24a. For All Wells: Original form to Division of Water Resources-(DWR),
/fwnter level is above casing,use"+' Information Processing Unit,1611 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Injection Wells:Copy1 to DWR,Underground Injection Control(IUC)
Program;1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: HSA
24c.For Water Suably 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 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:
F.-t:w-1