GW1-2021-05766_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: `T
l
Sam Bowers
v d rNA ERZO)I 5
FROM TO DESCRIPTION
Well Contractor Name 4 ^� ft. ft.
3220 A ft. ft.
(' r`'� 15OUTERGASG fdrnulfrcasednvells ORINERiflicalile
NC Well Contractor Certification Number ^ ,� FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. �1 ft. fr• 1n•
Company Name ;.�. )';'�' 2ti INNE WOMMU,B1NG o Lermal=closed Ioo _ x
V, FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 f" 5 ft. 2" in SCh 40 PVC
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): d37 SOREVN MEM
N
Water Supply Well: FROM TO - DIAMETER i SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 e• 20 ft. 2 i" 0.010 SCh 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) m ft. in. I
s.,18 GROU7�`up.
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 2 ft- Cement' Pour
Non-Water Supply Well: 2 fr. 4 ft- Bentonite Pour
IDMonitoring ❑Recovery
Injection Well: ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation i9: AD/GRAB";�iCK i7 �icable � _ '
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
4 fr. 20 ft. Sand
❑Aquifer Test ❑Stormwater Drainage
fr. ft.
❑Experimental Technology ❑Subsidence Control
£�2b:DRIGUING L�C3G"ah additional slt�et"stifi et�""ees"sa"';"', �x "'"
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiUmck type,grain sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 6 ft. Brown Clay
4.Date Well(s)Completed: Well ID#
07/22/21 MW-4 6 ft. 10 ft. Brown clayey silt
10 ft- 17 ft Tan silt
5a.Well Location: 17 f" 20 ft. Light brown silty sand
Baker Site n/a ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
204 West 18th Street, Kannapolis, NC
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): ZPermanent or ❑Temporary By signing this form,I hereby certify that the ivell(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 ofthis record Has been provided to the ivell owner.
If this is a repair,fill out known ivell construction information and explain the nature of the
repair under 921 remarks section or on the back ofthis 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: 1 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereni(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 10.97 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter• 6n (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
6" Solid Stem Auger 24aabove, also submit a copy ofthis 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
i
13a.Yield(gpm) Method of test:
24c.For Water Supply&Injection 1Wells:
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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
1

1
Ck-