WQ0005910_GW1 Form_20190916

«FLL CONSTRUCTION RECORD (GW -1)
1. %411 Contractor Tnformation:
Stuart Spruill
Well Contractor Name
2193
NC Well Contractor Certification Number
SGI
Company Name
2. Well Construction Permit #:
List all applicahle well ce natruciian permits (i.e. UIC, County. Scale. Variance. etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Municipal/Public
❑Geothermal (Heating/Cooling Supply)
LIResidential Water Supply (single)
❑lndustrialiCommercial
El Residential Water Supply (shared)
❑Irri ation
❑WOls> 100,000 GPD
on-Water Supply Well:Monitoring
F
FRUM TO DESCRIPTION
ft.
16. INNER CASING 01
❑ Recovery
IIAquifer Recharge
OAquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Gcothetmlal(Closed Loop)
❑Geothermal (Heating/Cooling Return
4. Date Well(s) Completed: 9/13/19
Sa. Well Location:
Avoca Farms
CGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
(71 Subsidence Control
❑Tracer
[]Other (explain under 921 1
Well ID# MW10
Facility Owner Namc Facility M*! (if applicable)
841 Avoca Farm Rd., Merry Hill, NC
Physical Address, City, and Zip
Berie
Comry Parcel Identification No. (PM)
51b. Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(ifwell field, one laulong is sufficient)
35.991725° .N76.7192690 W
6. Is(are) the well(s): InPermanent or ❑Temporary
7. Is this a repair to an existingwelL- ❑Yes or ONo
If this is a repair. fill out known well construction information and explain the nature of the
repair under =21 remarks cecrlor or on the hack of rhes form
S. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW -1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 20 (ft.)
For nndriple yells list all depths if diljerenl (example- 3 xi4200' and 2@107)
10. Static water level below top of casing: (ft.)
If uarer level is above casing, ase
IL Borehole diameter: 5.5 p
12. Well construction method: Auger
22. Certification:
i/ 9/1/2019
By signing this form, l7rer by cerrtfy that the" 11(x) wa.T (were) construcled in
19.1 VC.IC 0X.0100 o. 5.4 NC.IC 010.0210 well Cotsowc-not slandards
of this record has been pri vided to the nrll ovVier.
23. Site diagram or ai ditional well details:
You may use the ba6 of this page to provide additional well con
(add'See Over in Rem rks Box). You may alto attach additional pag
24. SUBMITTAL IN TRUCTIONS
Submit this GW -1 wi hin 30 days of well completion per the folli
24a. For All Wells: Original form to Division of Water Reso
Information l"ToCessitil Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection M ells: Copy to DWR, Underground Injection
Program, 1636 MSC, alcigh, NC 27694-1636
24c. For Water SUDD v and Open -Loop Geothermal Return Wel
(i.e. auger, rotary, cable, direct push, etc-) county environmental eallh department of the county
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Well roducin over 100000 GPI
Permit Program, 3611 SC, Raleigh, N 216 -)61 I
13a. Yield (gpm) Method of test:
Iib. Disinfection type: Amount:
Foran GW -I North Carolina Department of Environmental Quality . Division of ter Resources
cordance iri)h
id that a ropy
action info
if necessary.
ing:
res (DWR),
Dntrol (IUQ.
Copy to the
Copy to DW CCPCUA
6-6-2_019
For Internal Use 01 ly:
ft.
�3
ft.
14. WATER ZONES
multi -cased well OR L if apIieable
FROM TO
FRUM TO DESCRIPTION
ft.
16. INNER CASING 01
;
22. Certification:
i/ 9/1/2019
By signing this form, l7rer by cerrtfy that the" 11(x) wa.T (were) construcled in
19.1 VC.IC 0X.0100 o. 5.4 NC.IC 010.0210 well Cotsowc-not slandards
of this record has been pri vided to the nrll ovVier.
23. Site diagram or ai ditional well details:
You may use the ba6 of this page to provide additional well con
(add'See Over in Rem rks Box). You may alto attach additional pag
24. SUBMITTAL IN TRUCTIONS
Submit this GW -1 wi hin 30 days of well completion per the folli
24a. For All Wells: Original form to Division of Water Reso
Information l"ToCessitil Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection M ells: Copy to DWR, Underground Injection
Program, 1636 MSC, alcigh, NC 27694-1636
24c. For Water SUDD v and Open -Loop Geothermal Return Wel
(i.e. auger, rotary, cable, direct push, etc-) county environmental eallh department of the county
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Well roducin over 100000 GPI
Permit Program, 3611 SC, Raleigh, N 216 -)61 I
13a. Yield (gpm) Method of test:
Iib. Disinfection type: Amount:
Foran GW -I North Carolina Department of Environmental Quality . Division of ter Resources
cordance iri)h
id that a ropy
action info
if necessary.
ing:
res (DWR),
Dntrol (IUQ.
Copy to the
Copy to DW CCPCUA
6-6-2_019
ft.
ft.
I& OUTER CASING
multi -cased well OR L if apIieable
FROM TO
DIAMETER THICKNESS MATERIA L
ft.
16. INNER CASING 01
in.
TUBI'%EGeotbe al cbmed-loo
FROM t'O
lltA�lE7 ER TRICKESS MATERL L
-3 f[ 10
2 i" SCH40 PVC
ft.
17. SCREEN
FROM TO
DIAMETER SLOT "SIZE THICKNESS MATERIAL
10 ft. 20 n.
2 . in. 10 SCH40 PVC
rL 10 ft.
in.
18 GROAT
FROM I TO
MATERIAL i EMPLACEMEN METHOE & kMOUNT
0 fL 2
Cement I Poured
2 ft. 10BentomiW
Poured
ft151.
SAND/GRAVEL f CK if applicable) I
FROM TO
I MATFRIAt.
EMPLACEMFVT METHOD
10 ft. 20
L ,#2 Gravel
Poured
ft.
241. DRILLING LOG (axacb
additional sheets if n
FROM TO
I DESCRIPTION (e ]l . hardn , wiF-k e, ran sin, ete.)
0 ft. 2
Drk. Brwn Organic Soil
2 fL 8
Brwn F -M Sandy SILT
8 rt. 10
Lt. Brwn F -M Sandy SILT
10 ft. 15
• Lt. Brwn Silty F -M SAND
15 ft 17
LTan Silty F -M SAND
17 ft- 20
L Gray Silty F -M SAND
ft.
21. REMARKS
22. Certification:
i/ 9/1/2019
By signing this form, l7rer by cerrtfy that the" 11(x) wa.T (were) construcled in
19.1 VC.IC 0X.0100 o. 5.4 NC.IC 010.0210 well Cotsowc-not slandards
of this record has been pri vided to the nrll ovVier.
23. Site diagram or ai ditional well details:
You may use the ba6 of this page to provide additional well con
(add'See Over in Rem rks Box). You may alto attach additional pag
24. SUBMITTAL IN TRUCTIONS
Submit this GW -1 wi hin 30 days of well completion per the folli
24a. For All Wells: Original form to Division of Water Reso
Information l"ToCessitil Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection M ells: Copy to DWR, Underground Injection
Program, 1636 MSC, alcigh, NC 27694-1636
24c. For Water SUDD v and Open -Loop Geothermal Return Wel
(i.e. auger, rotary, cable, direct push, etc-) county environmental eallh department of the county
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Well roducin over 100000 GPI
Permit Program, 3611 SC, Raleigh, N 216 -)61 I
13a. Yield (gpm) Method of test:
Iib. Disinfection type: Amount:
Foran GW -I North Carolina Department of Environmental Quality . Division of ter Resources
cordance iri)h
id that a ropy
action info
if necessary.
ing:
res (DWR),
Dntrol (IUQ.
Copy to the
Copy to DW CCPCUA
6-6-2_019