GW1-2023-00537_Well Construction - GW1_20230104

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
David E. Meyer 14.WATER ZONES !:
FROM TO DESCRIPTION
Well Contractor Name
2527-A 10 ft• 14.5 ft surficial aquifer
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a licable)
Protocol Sampling Service, Inc. FROM TO DIAMETER THICKNESS MATERIAL
2.0 1- 9.5 ft. 2 Sch.40 PVC
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.U1C,County,State,Variance,etc.) ft. fL in,
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: FR SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 9,� ft- 14.5 ft' 2 in, 0.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑hr1 ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft, 6.5 fL Portland pour
❑Monitoring PJRecovery 6.5 ft- 8.5 ft- Bentonite pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 8.5 ft- 14.5 ft- #2 quartz sand pour
❑Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft• 1 ft. Dark brownish gray silty sand (SM)
4.Date well(s)Completed: 12/21/22 Well ID# RW-3 1 ft• 5 ft. Dark yellowish brown silty sand(SM)
5a.Well Location: 5 It' 14 ft- Gray fine to medium sand (SP)
McKee Homes LLC na 14 ft- ft. Greenish gray marl (refusal)
Facility/Owner Name Facility ID#(if applicable) ft. ft.
109 Hay Street Fayetteville NC 28301 ft. ft. "-
Physical Address,City,and Zip ft. ft, JAN 0 -
New Hanover -R04806-006-131-000 21.REMARKS
s
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
34�15.297' N 77 55.763' W � � 12/26/2022
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCcrtiried well Contractor Date
By signing this fm•nr,1 hereby certif that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [INO 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill ont 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-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: 14.5 (ft)
Formultiple wells list all depths ifdiiferenr(example-3@200'and 2@100) Submit this GW-1 within 30 days iof,well completion per the following:
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10.0 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
lfwater level is above casing.use
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11.Borehole diameter: 6 (in.) 2.4b.For Injection Wells:Copy to DWR,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:
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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
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