GW1--03403_Well Construction - GW1_20240610

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: t
1.Well Contractor Information:
David E. Meyer 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2527-A 33 ft- 37 ft• suffice!
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
Company Name
+3 ft. -27 ft• 2 in' Sch.40 PVC
16.INNER CASING OR TUBING(geothermal cloud-loop)
2.Well Construction Permit#: na FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.11KC',County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. r, in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural oMunicipalJPublic -27 ft• -37 ft. 2 in. 0.010 Sch.40 PVC
Geothermal(Heating/Cooling Supply) 10 Residential Water Supply(single) ft. ft. in.
Industrial/Commercial D Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 23.0 f
Portland Tremied
Monitoring Recovery 23.0 ft- 25.0 ft. Bentonite Tremied
Injection Well:
ft. ft.
Aquifer Recharge ❑Groundwater Remediation
Aquifer Storage and Recovery �{Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
.f tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 25.0 ft• 37.0 ft• #2 Quartz sand Tremied
-
Experimental Technology Di Subsidence Control ft. fL
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain sae etc.)
0.0 ft• 3 ft. Red clay
4.Date Well(s)Completed: 5/14/2024 Well ID# 5 3 it. 6 fiL Brown silty clay
5a.Well Location: 6 ft. 16 fb Yellowish brown micaceous sand silt
Thousand Trails Inc. 18 ft• 40 ff~ Yellowish brown micaceous sandy silt w/1/2•quartz peb.
Facility/Owner Name Facility lD#(if applicable) ft. f.
118 Thousand Trails Drive Advance NC 27006 ft. ft.
Physical Address,City,and Zip ft. ft.
Davie K900000000101 21.REMARKS r\L.V I:t �v f>w�'•'
County Parcel Identification No.(PIN) JUN 1 0 2624
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: V
(if well field,one lat/long is sufficient) 22.Certification: ingetatisiie it-e'GC3t►M U` 4
35.860491 80.395618 oteOiaO`,
N W w 4. 5/18/2024
�f 6.Is(are)the well(s)10Permanent or Temporary Signature of Certified W I_ontracror Date
By signing this form,/her cert fy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IDYes or @No with/5A N('A('02('.0100 or/SA N('AC'02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under n2/remarks section or on the hack of this form.
23.Site diagram or additional well details:
You may use the back of 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTILL CTIONS
9.Total well depth below land surface: 37 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2©l00) construction to the following:
10.Static water level below top of casing: 36 (ft.) Division of Water 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 Iniection Wells: 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 following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c. For Water Sumily& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016