GW1-2023-00536_Well Construction - GW1_20230104

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
David E. Meyer 14.WATER ZONES !
FROM TO DESCRIPTION
Well Contractor Name �
2527-A 10 ft- 13.5 ft• surficial aquifer
ft. ft.
NC Well Contactor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable'
Protocol Sampling Services Inc. FROM TO DIAMETER THICK,1IESS MATERIAL
1.5 ft- 8.5 ft• 2 SCh.40 JPVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• na FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counhl,State,Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8.5 ft- 13.5 ft- 2 i"' 0.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 8 5 ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 6.5 ft- Portland pour
❑Monitoring InRecovery 6.5 ft. 7.5 ft- Bentonite pour
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applica6le)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
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❑Aquifer Test ❑Stormwater Drainage 7.5 ft, 13.5 ft- #2 quartz sand 1pour
❑Experimental Technology ❑Subsidence Control ft. ft.
[]Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM To DESCRIPTION(color,hardness,sodfrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft. 5 fr. Brown silty fine sand (SM)
4.Date Well(s)Completed: 1 2/21/22 Well ID# RW-4 5 ft- 13.5 ft- Dark gray silty sand/sandy clay(SM/SC)
5a.Well Location: ft. ft.
McKee Homes LLC na 13.5 ft. ft. Greenish gray marl (refusal)
Facility/Owner Name Facility ID#(if applicable) ft. ft.
109 Hay Street Fayetteville NC 28301 ft. ft. I .� r •• _
Physical Address,City,and Zip ft. ft.
New Hanover R04806-006-131-000 21.REMARKS
County Parcel Identification No.(PIN)
�n1Lt1'ft•^v'4i c�i�l t�fi.'°.•«xj4r�t'.� i.l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
if well field,one lat/lon is sufficient)
C a g o 22.Certification
N W .
34 15.298' 77 55.762' 12/26/2022
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6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contactor Date
By signing this form,)herebv cert -that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or GNo 15.4 NCAC 02C.0100 at-15A NCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fell 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 I GW-I 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: 13.5 For (ft.) Submit this GW-1 within 30 days iof well completion per the following:
multiple wells list all depths if dierent(example-3@200'and 2@100�
10.Static water level below top of casing: 1 0,0 (ft) 24a. For All Wells: Original form;to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter 6 (in.) 24b.For Injection Wells:Copy to IDWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: auger 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: f I
13b.,Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources) Revised 6-6-2018