GW1-2021-05767_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: y;>
Sam Bowers � .,^��y� ,�]4.�W�t7'ERZONE3' � _' ��''
C ,.y FROM TO DESCRIPTION
Well Contractor Name � •' �
ft. ft.
3220 A `��� ft. ft.
C,� 15..011TER CASIN_ G,formulh-cased-»ells.OR ,INERT if-a licatile
NC Well Contractor Certification Number s
�• FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. e_, �;, ft. ft. in.
Company Name '�16.INNER'CASINGiOR 3 UBING;'eothecmal closed=loo a; _
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 10 it. 2a in. sch 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. fA in.
3.Well Use(check well use): 47 SCREEN;'' M,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/'Public 10 ft' 25 ft• 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) iq'•
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rL 7 ft- Cement
Non-Water Supply Well:
OMonitoring ❑Recovery 7 ft. 9 ft. Bentonite
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation J9:'SXNDIGRA'YFI PACk tfa'-7icable §ix
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 9 fa 25 ft' 'Sand
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control ;20.D1tILL1NG,LOC,attach aduiiional.sheet'slf neei Y
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 ft. Top soil
4.Date Well(s)Completed: 07/20/21 well ID#MW-1 1 ft. 5 ft. Brown silty sand
5 ft- 13 ft. Light brown sandy silt
5a.Well Location: 13 ft 18 ft Gray sandy clay
Baker Site n/a 18 ft. 20 ft. Light gray clayey sand
Facility/Owner Name Facility ID#(if applicable) 20 ft. 25 ft. Gray clayey sand
204 West 18th Street, Kannapolis, NC ft. ft.
Physical Address,City,and Zip
Rowan 28081
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
35.518971 N 80.616553 W 08/04/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the wetl(.$)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under d21 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 site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same eonstrnedon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiereni(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 20.58 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6" (in.) g
6 24b. For Iniection Wells ONLY: In addition to sending the form to the address in
6" Solid Stem Auger 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,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
24c.For Water Supply&Iniection;Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Amount: well construction to the county Health department of the county where
constructed.
i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013