GW1-2021-00611_Well Construction - GW1_20210205

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
i
Edwin Mullis 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
3518-A 160 ft 163 12
264 ft 266 fL 16
NC Well Contractor Certification Number '15.OUTER CASING for mold cased wells OR LINER if alicable
Gopher Utility Services, Inc FROM TO DIAMETER, THICKNESS MATERIAL
0 ft- 86 ft• 6 1/8 1 SDR 21 PVC
Company Name
333276 INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE. THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) ft. fa in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIALS EMPLACEMENT METHOD&AMOUNT
Non-Water Supply well: 0 It" 24 ft. Bentonite'Plug 83 Bags-Pour and Hydrate
[]Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
s19.SAND/GRAVEL PACK if applicable)
El Aquifer Storage and Recovery ❑Salinity Banter FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional"sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiltrock e, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 ft 20 f' Red Dirt
4.Date Well(s)Completed- 1/21/2021 quell ID# 20 ft• 40 ft• Brown Dirt
5a.Well Location: 40 ft' 70 ft- Soft Sandstone
Pat Musi 70 ft. 76 ft. Medium Sandstone
Facility/Owner Name Facility ID#(ifapplicable) 76 ft. 285 ft- Mingled Granite,Pink and Blue,with Quartz
1160 Gateway Dr, Mooresville, NC 28115 ft. ft.
Physical Address,City,and Zip ft. ft.
Rowan 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Certificltio
35 - 34' 39 N 80 - 44' 07 W
6.Is(are)the well(s): [!]Permanent or ❑Temporary Signature o Certified Well ContractorDate
By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 8No 15A NCAC 02C.0100 or 15A NCAC 02C.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 provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
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: RE 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 285 -4� I�I this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@I00')�I U
Cll 24a. For All Wells- Original form:to Division of Water Resources (DWR),
10.Static water level below top of casing: 25 l: �ft809�ormation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" %ai7p �''ll``
11.Borehole diameter: 6 1/8 (in.) DVV&rO%Sjn 4 For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
@cil'�n � ,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Air Rotary
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
i
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 18 Method of test: Air
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Sterileen Amount: 5 Caps
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20I8