GW1-2022-07818_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: j
1.Well Contractor Information:
Mike Tynan 1`4,WAIERZONES
FROM TO DESCRIPTION
Well Contractor Name —26 ft• 32 saprolite,pwr
2725-A
rr. rr.
NC Well Contractor Certification Number
�� 15,'OUTER- ASTYG'forii irlti cased hells OR LI1�lEI2"(fa' rcable� ,
FROM TO DIAMETER: THICKNESS MATERIAL �f
ft. ft. in.
CompatiyName 16.HVNER:CASINGC3ILII:IBI1VCr eothermfitclosed-lop Sl
WM0301221 / SIP-70003050 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State. 14ariance,etc.) 0 ft. 17 ft. 1 2 to Sch40 PVC
3.Well Use(check well use): ft ft. in
Water Supply Well: ,
FROM TO DIAMETER SLOTSIZE THICKNESS I MATERIAL
Agricultural ®Municipal/Public 17 rt- 32 rt' 2 tn' 0.010 Sch40 Prepacked PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft
Industrial/Commercial E3Residential Water Supply(shared) GR
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 12 ft. 15 ft- bentonite pour
X Monitoring ®Recovery ft ft.
Injection Well:,
rr. rt.
Aquifer Recharge Groundwater Remediation
.X9.'SAND/G,RAVEt PACK_If a i lichbk'
Aquifer Storage and Recovery ®ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage 15 ft- 32 ft- #2 silica sand pour
Experimental Technology ElSubsidence Control ft. ft.
9
Geothermal(Closed Loop) 13Tracer 40:1?RILLII G-1OC attach additional sheets if _
FROM TO DESCRIPTION color,hardness,soiltrock t e, grain size,etc.)
Geothermal(Heating/CoolingReturn) Other(ex lain under#21 Remarks) ft. ft.
See Consultant's Log
4.Date Well(s)Completed:8/1/2022 Well ID#TM V V-1 ft. R.
5a.Well Location:
rt. ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
325 Rhyne Rd, Charlotte 28214 ft. ft.
Physical Address,City,and Zip ft. If-
Mecklenburg x1.xEMARKs -
County Parcel Ideutification No.(PIN)
5b.Latitude and longitude in degrees/ntinutes/seconds or decimal degrees:
(if well field,one lat1ong is sufficient) 22.Certification:
35.287849 N 80.969951 8/11/2022
z�
6.Is(are)the well(s)�Perm SiLmiturc of Cer ed\Vefl Conbactor
anent or % Tempowary ), -4 ate ,.c
By signing this form,I hereby certfv that the nel(s):Gs.{uli o tcaasbrncteAZa6;dance
7.Is this a repair to an existing well: ®Yes or qNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 IVell Consi ucfron Standards and that a
If this is a repah;fill out known well construction information and explain the natum of the copy of this record has been provided to the well owner.A I r t� 9 f1�'�
repair under#21 remarks section or on the back of'this forn.
J 2 L h
23.Site diagram or additional well details: F'
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to well
construction,only 1 GW-1 is needed. hidicate TOTAL NUMBER of wells construction details. You may also attach additional orwaary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 34 (B-) 24a. For All Wells: Submit this form within 30 days of completion of well
Formultiple welts list ail depths ifditjerent(example-3&100'and2@100) construction to the following:
10.Static water level below top of casing:—26 Division of Water Resources,Information Processing Unit,
I1'wuter level is above casing,use "+" 1617 Mad Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Infection Wells: Art addition to sending the form to the address in 24a
auger, auger above, also submit one copy of this form within 30 days of completion of well
12. 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: 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 i the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016