GW1-2021-05771_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 �,'`-I =�'' 14.tVVt1TER;ZONES .µ., �� t. 1' ,
,�'.�'� FROM TO DESCRnPTION
Y'
Well Contractor Name mil`a ,r 0 ft. ft.
3220 A
NC Well Contractor Certification Number �,r r ,.15.OUTER GASI]\G for':inulh caseil3weIIs'OR LINER'ifa-"licab16
.x
` FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ' 0 40 5
,.�,'c ',S^ ft. ft. in.
Company Name
\;� ,16.ANNER)CASING 0R+T[7BING "e`othermi l closed=loo' y ,
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 rt' 54 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): 1:7 SGREEN,,
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 54 ft- 59 ff• 2 in. 0.010 sch 40 PVC
❑Geothermal(Heating/CoolingSupply) ❑Residential Water Supply(single) ft. tt. in;
PP Y) pp Y
❑Industrial/Commercial ❑Residential Water Supply
pp y(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 51 ft• Cement
Non-Water Supply Well:
RMonitoring ❑Recovery 51 ft. 53 ft• Bentonite
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 9�SAND/GRAVEL•PAGK(& pplicab9e`
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 53 r' 59 ft. S2nd
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
=20.DRILLINGLOGS'attach a0ilitional,sheeis'if;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• 10 ft• Brown silt
4.Date Well(s)Completed: 07/22/21 Well ID#TW-4 10 ft• 23 ft• Light brown silt
23 ft• 34 ft. Light brown silt minor clay
5a.Well Location: 34 fr. 39 ft. Brown silty minor clay
Baker Site n/a 39 ft• 40 ft• Weathered granite
Facility/Owner Name Facility ID#(if applicable) 40 ft- 58 ft. Weathered granite
204 West 18th Street, Kannapolis, NC 58 it. 59 tt. Bedrock
Physical Address,City,and Zip -2I.REMARKS„,''`t
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 wells)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 EJNo copy ofthis 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: 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: 59 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing:
12.41 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: tt (in.) g
4 1/2 24b. For Iniection 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
i
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.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of WaterfResources Revised August 2013
I