GW1-2021-00109_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 TO DESCRIPTION
2527-A 7 ft. 15 ft. surficial aquifer
rt. ft.
NC Well Contractor Certification Number 15:-UUTER'CASING for:multi-casedswetls"OR DINER"if a Deable ___
Protocol sampling Service, Inc. FROM TO DIAMTE ER THICKNESS MATERIAL
0.3 ft• 5 it 2 in Sch.40
Company Name PVC
161NNEWCASING,OR',TUBING 'eothefmalclosed-loo
2.Well Construction Permit#• na FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,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 I THICKNESS I MATERIAL.
❑Agricultural ❑Mrmicipal/Public 5 f" 15 it 2 In. 0.010" ISch.40 JPVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft- 5 ft In,
❑lndustrial/Commercial ❑Residential Water Supply(shared) -"518l(GROUT».:
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 2.0 ft- portland pour
❑Monitoring ❑Recovery 2.0 ft- 4.0 ft, bentonite pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.,SAND/GRAVELPACK(it a pfteable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 4.0 ft- 15 ft #2 quartz sand pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothemral(Closed Loop) ❑Tracer 20 DRILLINGIOG;attach additlotial sheets;if neiesia'
N FROM TO I DESCRIPTION color•hardness solFrock typA grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
A 0.0 ft- 1.0 it Black silty sand (SM)
4.Date Well(s)Completed: 11/1/21 well ID#AS-2 1.0 ft. 11.0 ft- Dark,'gray clay(CL)
5a.Well Location: 11.0 it• 16.0 ft. Gray'fine sand (SP)
Goff Grocery na ft. it•
Facility/Owner Name Facility iD#(if applicable) ft. ft. I
105 Peanut Court Goldsboro, NC 27530 ft. NOV 9 Z021
Physical Address.City,and Zip ft. ft.
Wayne 3601323126 AL REMARKS:': .
t
County Parcel Identification No.(PIN) TInll D'7(1(`rC
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifloation:
35.4274910 N -77.981629° W ' L 11/4/2021
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well d6ntractor 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 ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the native of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of thisform. 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: 15.0 (ft.
For multiple wells list all depths ifdifferent(example-3@200'and 2 a 100') ) Submit this GW-I within 30 days of well completion per the following:
10.Static water level below top of casing: 7.00 (ft) 24a. For Ali Wells: Original form to Division of Water Resources (DWR),
If wider level is above rasing,use +^If Processing Unit,16171MSC,Raleigh,NC 27699-1617
11.Borehole diameter.. 6 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
(in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: auger i
(i.e.auger,rotary,cable,direct push,etc.) 24c.For Water Su 1 and O ea-Loo Geothermal Return Wells:Copy to the
county environments health department o le county ere rnsta ed
I
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin 'over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,161 C,Raleigh,,NC 27 9-1611
131.Yield(gpm) Method of test:
13b.Disinfection type: Amount: b
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018