GW1-2021-07889_Well Construction - GW1_20211102

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Dan Imo- i el- Sumrn-_._ i
erS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
15 ft 25 ft-
2579-A ft ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Carolina Soil Investigations, LLC FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 15 ft 2 1n sch 40 pvc
16.INNER CASING OR TUBING eti'therroa]closed-loop)
2.Well Construction Permit#: Meck SIP#70002939 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 15 ft 25 ft. 2 in- 010 Soh 40 pvc
Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation Q Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
lGeothermal
n-Water Supply Well: 0 ft 5 ft portland mix&Pour
Monitoring Recovery 5 fL 13 ft bentonite tremie
ection Well: ft ft
Aquifer Recharge El GroundwaterRemediation 19.SAND/GRAVEL PACK Na livableAquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �StormwaterDrainage 13 ft 25 ft 10/30 Silica Sand tremie
Experimental Technology 0 Subsidence Control ft ft.Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG attachadditionil sheets if necessa(Heating/Cooling Coolin Return) FROM TO DESCRIPTION color,hardness soil/rock type, rain size,etc.
( g/ g ) �Other(explain under#2I Remarks)
0 ft 25 ft brown silt loam/brown silty clay/saprolite
4.Date Well(s)Completed:10/04/2021 Well ID# MW-1 MW-2 MW-3 ft ft
5a.Well Location: ft ft
ft ft RECEIVED
Facility/Owner Name Facility ID#(ifapplicable) ft ft
4806 Monroe Rd Charlotte, NC ft ft
Physical Address,City,and Zip
ft ft Information Processing Unit
Meck.
21,REMARKSSec-ii
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Cer t I tion:
35.19291 N -80.78086 N
10/04/2021
6.Is(are)the well(s):R Permanent or El Temporary Signature of Certificd Well Crntractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well:
Yes or El No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
lfihis 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#21 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-I is needed.Indicate TOTAL NUMBER,of wells construction details.You may also attach additional pages if necessary.
drilled: 3
SUBMITTAL INSTRUCTIONS,
9.Total well depth below land surface: 3@25 (ft.)
P-or multiple wells list all depths it different(eiranhple-3 tt 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: 22 (ft)lfwater 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 Infection 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,JUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t
13a.Yield(gpm) Method of test: 24c. For Water Supply& Injection 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 ro the county health department of the county
where constructed. i
Form GW-I North Carolina Department of Environmental Quality-Division ofWater Resources Revised 6-6-2018