GW1-2021-05770_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:
l)a4:WATfER`7ONES
Sam Bowers FROM TO DESCRIPTION
Well Contractor Name \:j1t1� ft. fL
3220 A ft.
,,,tom •i�
NC Well Contractor Certification Number
' t'•O 15:OUTER CASING ftirmulh,ca'sed;+ell's OR?TWER'ifa licatile' '
"•,'.•''-��ti,` FROMTO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. o,'• o 130 15 i
Company Name CANNEWCASINGlOR$7, BING;(d`othermal'closed=too
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 40 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): 17:nSCREEN" -
,911
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 40 ft' 45 tt• 2 in' 0.010 sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 37 ft- Cement
Non-Water Supply Well: 37 ft. 39 fc. Bentonite
2Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation u19`SAND/GRAVEI P,AGKi if airplieable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 39 ft. 45 ft. Sand
❑Aquifer Test ❑Stormwater Drainage
ft, ft.
❑Experimental Technology ❑Subsidence Control
:,'2 0.1 D R I U U I NG li0Gf attach additional heets`)it:necessa
❑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:
07/21/21Well ID#TW-3 1 rL 5 ft. Light brown silt
5 fc. 8 ft. Tan sandy silt
5a.Well Location: 8 rc• 12 tc• Light brown sandy clay
Baker Site n/a 12 fr 22 fr Brown silty sand
Facility/Owner Name Facility ID#(if applicable) 22 ft. 28 ft. Brown weathered rock
204 West 18th Street, Kannapolis, NC 28 ft. 30 rc• Gray weathered rock
Physical Address,City,and Zip 2L`REIITARKS � � "
Rowan 28081 30'-44'Weathered granite 44'-45' Bedrock
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one laOong is sufficient)
35.518971 N 80.616553 W 08/04/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I 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 FIND copy of this 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 tinder 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: 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:45 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:
13.11 Division of Water Resources,Information Processing Unit,
(ft.)
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 1/2" (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
24aabove, also submit a copy of this form within 30 days of completion of well
Air Hammer/ air rotary
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.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013