GW1-2021-05738_Well Construction - GW1_20210706

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor:information:
Donald Warren ® _ 14:"WATERZONE5 ,...,
FROM - TO= DESCRIPTION
Well ContractorName ft. ft,
3581-A JUL 0 S 2021 ft. ft.
s.
NC Well.Contractor Certification Number M , pCCcegsing . -;OUTER CASING(formula cased wells OR`LINER if a`" rcable .
Mid South Environmental, Inclnfioll�at`on FROM TO?_ DIAMETER THICKNESS MATERIAL
n��;r�Seorion
ft. ft.
tin.
CompanyIJame &INNER CASING OR TWLNG, W1i4 aial closed-[oo
2.Well Construction Permit if: FROM I TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(r e.UIC,County,State,Variance,etc.) IL ft. in.
3.Well Use(check well use): m
,37:SCREEN
Water Supply Well: 1.
P FROM TO s DIAMETER SLOT SIZE t TffiCIGY£SS MATERIAL
Agricultural OMunicipaVPublic it & io
Geothermal(lieating/CoolingSupply) Residential Water Supply(single) R ft in.
industrial/Commercial oResidential Water Supply{shared) 1g;GROITf. _
irrigation
.FROM... . TW - MATERIAL .EMPLACEMENT.-METHOD&AMOUNT
Non=Water Supply Well: ft. ft
x Monitoring _ E)Recovery ft. ft.
Injection Well:
ft. ft.
Atiuifer Recharge Grotmdwater Remediation ;49.SAND/GRA 1 L PACK(if a 'ce6te
Aquifer:Storage and':Recovery DSalinity.Barrier FROM Toi -I AIATERIAL - EMP.I.ACEMENT.METHOD
Aquifer Test [38tormwater Drainage
:)Experimental Technology Subsidence Control' ft. ft.
Geothermal(Closed Loop) DTramt '40 DRILLING-LOG.attachi dditionalsheet;ifnecessa ;
FROM. - TO'., DESCRIPTION coldr,hardness,sodhoek m sae•ete
Geothermal(Heating/Cooling Return) _) Other(explain under#21.Remarks) &
a.Hate Well(s)Completed:3/2612021 well IDxMW-13 ft ft.
ft. ft.
5a.Well Location:
Radiator Specialty Company ft ft' _ .
Facility/owner:Name Facility ID#(ifapplicable) ft. ft.
600 Radiator Road, Indian Trail, NC 28079 ft ft
ft.
Physical Address,City,and Zip .. ft.
Union 21.?REAlARKS s
County Parcel Identification No.(PIN)
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laillong is sufficient) 22:Certification:
35 03' 45.28" N 80 39' 01.24" «, 416/2021
� .._
6.Is(are)the well(s)x Permanent or _Temporary Signature ofCeftifled Well Contractor Date
By signing this foinb I hereby certify that the well(s)was(were)constructed in accordance
7i is this a repair to an existing well: Ex Yes or ONo with ISA NCAC 02C.0100 or ISA NCAC 02C::0260 Well Construction Standards and that a
If this is a repair,fill out known well crnutrucaon:informalion and explain the nature of the copy.of this record has been provided to the well owner.
repair under P21 remarks section or on the back of this form. 23 Site diagram or additional well details:
8.For Geoprobe/OPT or Closc&Loop Geothermal Wells having the same You may use the back of this page'to provide additional well site details or well
construction details. You may attach additional pages if necessary.
construction,only l GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS.
9.Total well depth below land surface (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@1200'and 2@100') construction to the following:
i
10.Static water level below top of casing: (M) Division of Water Resources,Information Processing Unit,
lfwater level is above casing use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For.Inieciion Wells: In addition to sending the form to the address in 24a
above.also submit one copy of this.for'm within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division ofWaterResources,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&Inlection Wells: In addition to sending the forth to
the address(es) above, also submit;one copy of this fort within 30 days of
13b.Disinfection type: Amount completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource s Revised 2-22-2016

LL ABANDONMENT RECQRD
31412,021.
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