GW1--03404_Well Construction - GW1_20240610

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 8 ft• 15 f surficial
ft.
NC Well Contractor Certification Number
15.OUTER CASING(tor multi-cased wells)OR LINER(if applicable)
Protocol Sampling Service, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
+3 ft. -5 R. 2 in' Sch.40 PVC
Company Name
16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: na FROM TO DIAMETER THICKNESS MATERIAL
List al/applicable well construction permits(i.e.(/1(',County,Slate,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 5 R 15 D z in 0.010 Sch.4o PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 3.0 R• Portland Poured
Monitoring ORecovery 3.0 ft• 4.0 tt. Bentonite Poured
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test f Stormwater Drainage 4.0 ft• 15.0 ft- #2 Quartz sand pour
]Experimental Technology Subsidence Control to R
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
( g/ g n tther(explain under#21 Remarks) 0.0 R• 2 ft• Red clay
4.Date Well(s)Completed: 5/15/2024 Well ID#4R 2 ft' 4 ft' Yellow sandy clay
5a.Well Location: 4 R• 10 fl• Gray clay
Thousand Trails Inc. to ft• 15 fL Grayish brown clayey fine sand
Facility/Owner Name Facility 104(if applicable) ft. ft.
118 Thousand Trails Drive Advance NC 27006 ft. ft.
Physical Address,City,and Zip ft. ft. ♦ti th„r L I 'J`fv
..
Davie K900000000101 21.REMARICSJUN 1 d 2)3Z4
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Irdbrmai,en 10e4G:wain.LAW
(if well field,one lat/long is sufficient) 22.Certification: IWQ'1042
35.865639 N 80.392428 w 4 A t 5/18/2024
6.Is(are)the weU(s)0Permanent or Temporary Signature ofCertifiedd WYeelll-Contractor Date
By signing this form,I herby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or EINo with/3A NCAC 02C.0100 or 15A NC'AC 02('.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 g2I 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 INSTRUCTIONS
9.Total well depth below land surface: 15 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd different(example-3@200'200'and 2G 100') construction to the following:
10.Static water level below top of casing: 11 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mal Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.5 (in.) 24b. For Iniection We Is: In addition to sending the form to the address in 24a
12.Well construction method: auger above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary, construction to the following:
ge 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 Supply& 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.
Font GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016