GW1-2022-06223_Well Construction - GW1_20220620

i
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 12.5 ft. 18.0 ft- fine sand
ft. ft.
NC Well Contractor Certification Number 15.bT1TER:CASING for.multi-casea'wells OR LINER if a Ilcable _
Protocol Sampling Service, Inc. FROM
TO DIAMETER THICKNESS MATERIAL
Company Name -0.3 ft. 18 ft 12 in. ISch.40 JPVC
16.INNER CASING OR TUBING eothermal'ciosed-loo
2.Well Construction Permit#: n a FRONT TO 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. it. in.
Water Supply Well: 17rSCREEN:. . -FROM TO DIAMETER I SLOTSIZF. I THICKNESS I MATERIAL.
❑Agricultural ❑Municipal/Public 8 it. 18 ft. 2 in. 0.010 Sch.40 JPvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 8 ft. In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Suppl � p 0.0 ft' 4.0 ft, Portland pour
OMonitoring Y'h �"'' -xr 1E9It~ec6very ft. ft-4.0 6.0 Bentonite pour
Injection Well: JI V IN J it n 202�
Aquifer Recharge Groundwater Remediation
❑
19.'SAND/GRAVEL PACK'ifia livable
❑Aquifer Banier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test D1A'C;60G ❑Stormwater Drainage 6 it. 18, ft. #2 quartz sand 1pour
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING'LOG.attacli'addittonal sheets.if necessa.
❑Geothermal(Heating/Cooling Return) [:]Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,soiurock typa grain sire,etc
�A� 0 ft' 2 ft- Reddish yellow silty fine sand (SM)
4.Date Well(s)Completed: May 26,2022 Well ID# M y -2 2 it. 6 ft. Gray sandy clay(SC)
5a.Well Location: 6 u. 7 it Gray silty fine sand (SM)
Former Merita Bakery na 7 ft 10 ft Black fine sandy clay(CL)
Facility/Owner Name Facility ID#(ifapplicable) 10 ft. 13 ft, Lt brownish gray clay(CL)
601 Ramsey Street Fayetteville, NC 28306 13 ft' 15 ft- Gray clayey fine sand/sandy clay(SC/CL)
Physical Address,City,and Zip 15 ft' 18 ft- Gray silty fine sand (SM)
Cumberland 0437-67-4705 2LREMARKs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlong is sufficient) tion;
35.062752 N 78.878205 W
� 5/26/2022
6.Is(are)the well(s): InPermanent or ❑Temporary Signature of Certified W I Contractor Date
Br 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 InNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repah-JI'll 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 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 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: 18.0 (ft.)
For multiple wells list all depths ffdierent(example-3(am200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 12•60 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
if water level is above casing use"+' Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:6.5 (in) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1G36
12.Well construction method: auger
24c.For Water Supply and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where insta led
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 120,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1511 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018