GW1--04747_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD(GW-1) For Internal Use O'ily:
1.Well Contractor Information:
David E. Meyer 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2527-A 5.5 ft 13.0 ft surficial aquifer
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(fur multi-cased wells)OR LINER(if ap liable)
protocol Sampling Service, Inc. FROM TO DIAMETER THICKNESS MATERIAL
+3.0 ft -3.0 fL 2 Sch.40 PVC Company Name
16.INNER CASING OlA TUBING(geothermal closed-loop)
2.Well Construction Permit#: na FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC.County,State,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 ❑Municipal/Public -3.0 ft -13.0 ft 2 in. 0.010 Sch.40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) rt. -3.0 ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Iti GROUT
•
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: +0.33 ft• -2.0 ft. Concrete Pour
Monitoring ❑Recovery -2.0 ft. -2.5 f Bentonite Pour
Injection Well:
ft.
❑Aquifer Recharge OGroundwater Remediation
❑Aquifer Storage and Recovery ❑Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
tY FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage -2.5 ft -13.0 ft. #2 quartz sand pour
❑Experimental Technology OSubsidence Control ft. f.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(awch additional sheets if necessary)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type grain rQe eft.)
0.0 ft. 1.0 f'• Yellowish brown fine sand(SM)
4.Date Well(s)Completed: July 17, 20 ,ell ID# 18 1.0 ft. 5.0 f- Brown fine sand(SM)
5a.Well Location: 5.0 fL 13.0 f- Grayish brown silty fine sand(SM)
Pine Island-Currituck Club WN1? WQ0004823 ft. fa p
Facility/Owner Name ft. 0. 7 t`--• 4,• i••, jr' 1,...i-i'
ty Facility ID#(if applicable)
I ine Island-Currituck LLC 106 York Way Bermuda Rul ft. ft AUG 1 2 2024
Physical Address.City,and Zip 41' 2146 ft. ft.
Currituck 0117000001 H0000 21.REMARKS
County Parcel Identification No.(PIN) Static water table at-2.50'bls;set well screen sfiallciW but with enough
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
concrete to prevent any surface contaminants from entering well
(if well field,one lat/long is sufficient) 22 :36.289 N -75.805 W 7/
.f)•fr. 7/18/2024
6.Is(are)the well(s): C1 Permanent or OTemporary Signature of Certified wolf Co actor Date
By.signing this,forms,/hereby certify that the well(,)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ifiNo I SA N('AC 02('.0100 or/SA N('AC 02('.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been prat ided to the well owner.
repair under 21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 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: 13 ft
For multiple wells list all depthsifdijferent(exmnple-3@ 200'and 2@100') ( ) Submit this GV1'-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 5.50 (ft)
24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above curing,use" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 6.5 (in.) 24b. For Injection We Is: 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 NSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Wattr Resources Revised 6-6-2018