GW1-2021-07888_Well Construction - GW1_20211102

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
r� �+ i
Llanlel JUm- ers 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 13 fL 23 fL
2579-A rt ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a liceble
Carolina Soil Investigations, LLC FROM TO DIAMETER THICKNESS MATERIAL
0 fL 13 fL 2 i� sch 40 pvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#; DEQ#WM030115-and-Meck#7000293 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL fL in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural IlMunicipal/Public 13 R. 23 f. 2 in. 010 sch 40 pvc
Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) fL ft
in.
Industrial/Commercial []Residential Water Supply(shared) 18.GROUT
Irrigation El Wells>-100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 5 ft. portlandl mix&Pour
Monitoring 17771 Recovery 5 fL 11 FL bentonite tremie
Injection Well: ft. FL
Aquifer Recharge 171 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage 11 fL 23 fL 10/30 silica sand tremie
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) El Tracer 20.DRILLING LOG.attach additional sheets if necessary)
Geothermal(Heating/Cooling Coolin Return FROM TO DESCRIPTION color,hardness soil/mck rain size etc.
( g/ g ) El Other(explain under#21 Remarks)
- 0 fL 23 fL brown silt loam/brown silty clay/saprolite
4.Date Well(s)Completed:10/21/21 Well ID# MW-2 ft. fL
5a.Well Location: ft. fL
Griffin Oil Company fL ft.
Facility/Owner Name Facility ID#(ifapplicable) fL ft.
7922 Penny Place Lane Mint Hill, NC ft. ft. NOV
Physical Address,City,and Zip
ft. fL
Meck 21.REMARKS
County Parcel Identification No.(PIN) DWR v
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iattlong is sufficient) 22.CertI IC on:
35.17867 N -80.64776 W 10/21/21
6.Is(are)the well(s):M Permanent or 0 Temporary Signature ofCedified Well wnaCtor Date
7.Is this a repair to an existing well Yes or No By signing this farm,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
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 41I remarks.section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed.Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary.
drilled: 1
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 23 (170
Tor multiple wells list all depths ifd fferent(example-3 a 00'and 2@100') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 18 (ft.)
If water level is above casing,use"+' Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8" (in.)
24b. For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: auger above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
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& Iniection Wells: In addition to sending the form to
the address(es) above, also submit,one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
I
I'
Form GW-1 North Carolina Department of Environmental Quality-Division ofWater Resources Revised 6-6-2018