GW1-2021-02389_Well Construction - GW1_20210727

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1,Well Contractor Information:
Gray Sherrill FROM TO DESCRIPTION
Well ContmotorNamc fL 375 ft- ' 150
2220-A ft. ft.
NC Well Conhaclor Certification Number FROM I TO DIAMETER TMCICMS MATERLIL
McCall Brothers, Inc. 0 ft. 42 ft. 8 ' in. 375 galvanized
Company Name b. ItsU: he?oisill�i 4
FROM TO DIAMETER TRIG NM MATERIAL
2.Well Construction Permit#: 10011433 ft. ft. in.
List all applicable well construction permits(i.e.County,Stair-'Variance,etc.) ft. ft. in.
3.Well Use(check well use): nTffl?`fitE1
Water Supply Well: FROM TO DIAMETER SLOTSUZ rHIC[CNESS MATERIAL
ft. ft. in.
❑Agricultural OMunicipal/Pablic
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. In.
❑/ndustrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD s&AMOUNT
Non- lionWater Supply Well: 0 ft. 31 ft. bentonite gravity Flow
Non- ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation U0gSl.
OA uifer Storage and Recovery ❑Stlllrli Barrier
FROM TO MATEML EMPLACEMENTMETHOD
4tY ty ft- ft.
❑Aquifer:Test OStormwater Drainage
❑Experimerdal Technology ❑Subsidence Control tt tt
❑Geothemmai(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color.bardouet wilhack IyM g2vin far,etc.
❑Geothemial(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 18 ft- Brown dirt
to ft* 25 ft. weathered rock
4.Date Well(s)Completed:
6/7/2021
25 ft- 42 ft- black rock
S.Well Location:
42 ft- 400 ft- granite
Sharon view place 10687b ft, n.
Facility/Owner Narne Facility M#(if applicable) ft.
16762bentridgedrive Charlotte nc 28226 ft. ft.
Physical Address,City,and Zip s
Mecklenburg 211-451-90 Uljjq
County Parcel Identification No.(PIN) rtJ0f 3Wn t Pr.:itJ(l
5b.Latitude and Longitude in degmes/minutes/seconds or decimal degrees: 22.Certification: 1
'(if n•ell field,one lattlogg is sufficient)
�/A 6/7/2021
35007'31.0692" N 80047'34.9584", R'
Signature of Certified Well Contractor Date
6.Is(are)the well1lormanent 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: [Dyes 00NO copy of this record has been provided to the well owner.
If this is a repair,fill out knowrt well construction information and explain the nature of the
repair under#21 remarks section or on the back of this farm. 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,your can
submit one fornG 24.Submittal instructions:
9.Total well depth below land burface: 400 (ft.) 24a: For All Wells: Submit this form witb}n 30 days of completion of well
Far multiple wells liar all depths if different(examjnle•3@200'and 2@100 construction to the following:
i
10.Static water level below top of casing: 30 (ft.) Division of Water Quality,4nformation Processing Unit,
If water level is above casing,use"+" 16.17 Mail Service Center,Raleigh,NC 276994617
il.Borehole diameter:
8 (in.) 24b.For Inieetion Will: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: air rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield Method of test: air left 24c.For Water Sunnly&Geothermal Wells: In addition to sending the form to
(gutm) 150 the addms(es)above, also submit one copy of this form within 30 days of
chlorine Amount: 13.5 completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
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Form GW-1 North Carolina Departncnt of Environment and Natural Resources-Division of Water Qiuriity Revised Jan.2013