GW1-2021-02450_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: f
David E. Meyer '14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION.
2527-A 4 fL 15 ft• surficial water table
NC Well Contractor Certification Number
:15.OUTER CASING.for mold-cased wells OR 1 INER.if a licnble
Protocol Sampling Service, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name +3 ft- _5 ft. 2 In. I Sch.40 JPVC
16.INNER+CASING OR TUBING alclosed4000l
osed400
2.Well Construction Permit#: na FROM TO DIAMETER THICKNESS I MATERIAL '
List all applicable well construction pennits 6.e.U1C,County.State..Variance•etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: '17.SCREEN.-_ -
FROM TO DIAMETER SWTSIZE I THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic -5 ft. -15 ft- 2 I" 0.010 SCh.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. -5 ft. in,
❑IndustriaUCommercial ❑Residential Water Supply(shared) 1R GROUT :.
❑Itri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0•0 ft' 3.0 ft- Portlandlconcrete pour
ClMonitoring ❑Recovery 3.0 ft- 4.0 ft- Bentonite pour
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑$alinity Barrier 19.SAND/GRAVEL PACKf aIlcnbleFROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 3.0 ft• 15 fL #2 quartz sand 1pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer .20.DRU LING-LOG attach additional sheets if necessary) _-
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,bardaM solllrock tM grain size ete.
0.0 ft. 2.0 ft. Black sandy clay(CL)
4.Date Well(s)Completed: July 15,2021 Well ID#PMW-1 2.0 ft. 9.0 ft. Grayish brown sandy clay(CL)
5a.Well Location: 9.0 ft' 15.0 ft• Gray clayey very fine sand (SC)
House of Raeford Farms, Inc. ft. ft,
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. vah
Fort Knox Road & Johnson Pond Road ft. ft,
Physical Address,City,and Zip ft. ft.
Duplin 247000925814 21:IlEnfARKs
County Parcel Identification No.(PIN) t CES0,1I19
I�garl; Sgcrlo
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: R
(if well field.one lat/long is sufficient) 22.CerHtication:
34°5'1.280' N 78`�4.362' w �� �A' 7/19/2021
6.Is(are)the well(s): MPermanent or ❑Temporary Signature ofCcrtified Well ntmctor Date
By signing this farm,I hereby cerlifi,that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or LhNO ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
!f this 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 the hack of this form.
23.Site diagram or additional well details:
S.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: $ (ft')multiple wells list all depths
F Submit this GW-1 within 30 days of well completion per the following:Forif different(example-3@200'and 1 n!00')
10.Static water level below top of casing:4.82 (ft,) 24a. For All Wells: Original Form to Division of Water Resources (DWR),
/jwater level is above casing,use Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: $ 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
(In.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: HSA
(i.e.auger,rotary, 24c.For Water Su I and O en-Loo Geothermal Return Wells:Copy to the
g tary,cable,direct push,etc.) county environments health department o the county where insta
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinp over 101,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27 -1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: