GW1-2022-07820_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 6
DAVID HALL „14.,WATERZONES
Well Contractor Name FROM TO I DESCRIPTION
A - 4459 ft. ft.
NC Well Contractor Certification Number "IS OUTER,CASING for multi-cos 6d yells OR LINER'if;a licatile
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. P in.
Company Name
16.INNER CASING OR TUBING 'eothermal closer!466"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stare,variance,etc.) 0.0 ft- 8.0 ft- 2.0 1°• SCH 40 PVC
3.Well Use(check well use): ft• ft.
Water Supply Well: .17.
FROM TO DIAMETER � SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8.0 ft' 18.0 ft' 2.0 '" .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ';18.,GROUT �,.
❑bTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0•0 ft- 3.0 ft PORTLANDBENTONTTE SLURRY
Monitoring ❑Recovery ft. ft.
Injection Well: it. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.°SANDIGRAVEI PACK`if a'"li2h fie' a
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 6.0 ft- 18.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer .20'DIRILLINGLOG ettaih:iidditid iii sifeets if hicessa
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck e, 'n size,etc.
0.0 ft- 14.0 ft. FILL
4.Date Well(s)Completed: 07/07/22 Well ID# MW-1 14.0 fit• 18.0 fit• PWR
Sa.Well Location:
ft. ft.
RLI TRUCKING ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2423 BERRYHILL ROAD CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip
ft. ft.
MECKLENBURG '21.RE11IARKS'i L
County Parcel Identification No.(PIN) BENTONIfE SEAL-3.0-6.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certification:
350 13' 18.54" N 800 52' 45.88" W �
07/18
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor ` Pali 'L
By signing this form,I hereby certify that the well(s)was(were) nsc i pp��cordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well rracgbn F.ZJktnd that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe ofihis record has been provided to the well owner.
repair under#21 remarks section or on the back ofihis form.
23.Site diagram or additional well det911 C'iYii1KD'1 i�r`n-W zin0 UrA
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide addt`3Y'o'-AWARanstruction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 18.0 (ft.)
For multiple wells list all depths ifdi/ferent(example-3@200'and 2@100) Submit this GW-1 within 30 days;of well completion per the following:
10.Static water level below top of casing: 16.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
$-0 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018