GW1--03401_Well Construction - GW1_20240610

WELL CONSTRUCTION RECORD (GW-1) For Internal Use 0 ly: loimiNT--
I.Well Contractor Information:
David E. Meyer 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2527-A 28 fe• 36 surficial
ft. .
NC Well Contractor Certification Number
15.OUTER CASING(f multi-cued wells)OR LINER(if ap liable)
Protocol Sampling Service, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name +3 ft. -26 • 2 in. Sch.40 PVC
16.INNER CASING O' TUBING(geothermal closed-loop)
2.Well Construction Permit#: na FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(//C,County,Stale,Variance,etc.) ft. f in.
3.Well Use(check well use): ft f. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public 26 ft• 36 ft. 2 1n. 0.010 Sch.40 PVC
Geothermal(Heating/Cooling Supply) IDResidential Water Supply(single) ft• rt. in.
Industrial/Commercial 0 Residential Water Supply(shared) IL GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 22.0 Portland Tremied
Monitoring DRecovery 22.0 fe• 24.0 f• Bentonite Tremied
Injection Well:
ft.
Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recovery �{Salini Barrier 19.SAND/GRAVEL PA K(if applicable)LI tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 24.0 ft- 36.0 #2 Quartz sand Tremied
Experimental Technology 0 Subsidence Control ft. f
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(a-ch additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock lroek type grain sae,etc.)
0.0 ft• 3 f Red Gay
4.Date Well(s)Completed: 5/1/2024 Well ID# 7 3 ft• 16 Brownish red sandy silt
5a.Well Location: 18 tt• 38 f Grayish white micaceous sandy silt
Thousand Trails Inc. 38 ft• 41 f Yellowish brown micaceous sandy silt w/1/2"quartz peb.
Facility/Owner Name Facility ID#(if applicable) ft.
118 Thousand Trails Drive Advance NC 27006 ft. f __ _ ' ;_.:
Physical Address,City,and Zip ft. ```.,L.i V 1,U
Davie K900000000101 21.REMARKS J U N 1 0 2924
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ingot lwen r'rsc4rsa+f►P U
(if well field,one lat/long is sufficient) 22.Certification: I arptJN
35.858542 N 80.392764 M 1 5/18/2024
6.Is(are)the well(s)JPermanent or oTemporary Signature of Certified Well ontractor Date
By signing this form,/her by certfy that the we/l(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or lallo with/SA N(AC 02('.0100 or/SA N('AC'02('.0200 Well Construction Standards and that a
If this is a repair,,nll out known well construction information and explain the nature of the copy of this record has bee provided to the well owner.
repair under u2/remarks section or on the hack of this firm.
23.Site diagram or ad.itional well details:
You may use the back f this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. Yo may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTR CTIONS
9.Total well depth below land surface: 36 (ft.) 24a. For All Wells: ubmit this form within 30 days of completion of well
For multiple wells list all depths if different(example-41200'and 2@100) construction to the folio ing:
10.Static water level below top of casing: 31.U6 (ft.)
Division of ter Resources,Information Processing Unit,
If water level is above casing,use'+' 1617 Mai Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.5 (in.) 24b. For Injection We I s: In addition to sending the form to the address in 24a
auger above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the folio 'ng:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water ' sources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mai Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Stool & Iniection Wells: In addition to sending the form to
the address(es) above, •Iso submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well con.truction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Wat r Resources Revised 2-22-2016