WI0600234_Well Construction Record_20220119

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 3 ft, 12.5 ft, surficial aquifer
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Protocol Sampling Service, Inc FROM TO DIAMETER THICKNESS MATERIAL
0.3 ft• 2.5 ft. 2 in• sch.40 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO _ DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: na
List all applicable well construction permits(i.e.U/C.County,State,Variance.etc.) ft. ft. m•
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER _ SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 2.5 ft. 12.5 ft. 2 in. 0.010 sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• 2.5 ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
El Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 1.0 ft, concrete/cement gravity pour
(!Monitoring ❑Recovery 1.0 ft, 2.0 ft. Bentonite gravity pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO _ MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStonnwater Drainage 2.0 ft. 12.5 ft. #3 quartz sand pour
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets If necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(cobs hardness,soil/rock type,grain size.etc.)
0.0 ft, 1.0 ft. Black silty sand (SM)
4.Date Well(s)Completed: Oct.4,2021 Well ID# MW-4R 1.0 ft, 3.0 ft- _Yellowish red sandy clay(SC)
5a.Well Location: 3.0 ft. 10 ft- Gray clayey sand (SC)
Country Store & Feed na 10.0 ft. 13.0 ft. White clayey sand (SC)
Facility/Owner Name Facility ID#(if applicable) ft. ft.
7828 Deep Branch Road Pembroke, NC ft. ft.
Physical Address,City,and Zip ft. ft.
Robeson 934302764527 21.REMARKS
The wee replaces orSonl AMW-0 d to.Well screen eel het e high season'no who.table hove.reco,e,d In olgVg0 AIMS.
Courtly Parcel Identification No.(PIN)
David E.Meyer, P.G.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cert•fication:
34'39' 49.54" N 79.11' 50.59" W
t/,) 10/5/2021
6.Is(are)the well(s): DPermanent or ❑Temporary Signature f Certified Well Contra r Date
By signing this farm,!hereby cert Ji,that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or L'1No ISA NCAC 02C.0100 or ISA NC.4C 02C.0200 Well Construction Standards and that a copy
!phis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the ue1l owner.
repair under#21 remarks section or on the back of this farm. 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.)
Fornu ltiple wells list all depths If different(stamp's-3�i?200'and 2qi l00) Submit this GW-1 within 30 days of well completion per the following:
7,�j0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
• 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 8 (in.)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: HSA 24c.For Water Supply 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: _
Forst GW-1 North Carolina Denartment of Environmental Onality-Division of Water Recnnrees Revised 6-6.201 R