GW1-2021-05765_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 1
Sam Bowers Q^a�^{ ' ;141VATER
:"y ;`�� FROM TO DESCRIPTION
Well Contractor Name a'a �Q ft. ft.
3220 A
r IVOUTERyCASiIVG,formitlhcastvlNells'OR'1INER i a plicgbleTt.94 :
NC Well Contractor Certification Number , `; ��r \Q\ FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ,�� ,;u' 0 ft. 40 ft. 5 i"•
1
Company Name 16:^INNER'CASING?OR ,BIM31(cot he'rmallclosed=loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 r" 40 ft. 2" in. sch 40 PVC
List all applicable well permits(i.e.County,Stale, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17ASCREEN. . > �'
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 40 ft' 60 ft 2 iM 0.010 1 sch 40 1 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. ft. inr
❑industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft' 51 rt• Cement
Non-Water Supply Well: 51 ft 53 rt Bentonite
OMonitoring ❑Recovery
injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19-SAND/GRAV.EL PAGI if iOpliehble-%
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 53 tt• 60 ft' Sand
❑Aquifer Test ❑Stormwater Drainage ft. fa
❑Experimental Technology El Subsidence Control
20 DRILL-NGiCMittach,additio al sheefss.ifiiecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock 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#TW-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 rt. 20 ft. Light gray clayey sand
Facility/Owner Name Facility iD#(if applicable) 20 ft. 26 ft Gray clayey sand
204 West 18th Street, Kannapolis, NC ft. ft.
26 33 Light brown clayey sand
Physical Address,City,and Zip F,
Rowan 28081 33'-40' Light brown sand;40'-42 Light brown sand;
County Parcel Identification No.(PIN) 42'-60'Weathered granite with quartz
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): GaPermanent or ❑Temporary By signing this form,1 hereby certify that the well(-s)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 ElNo copy ofthi.s record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
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 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 construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 60 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 12.67 (ft•) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
s
11.Borehole diameter: 4 1/2" (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Air Hammer/ air rotary 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
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection;Wells:
Also submit one copy of this form within 30 days of completion of
13b.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
i

J I
y �
(�a
Y N aos
a5
30
Za
Zb9 s