GW1-2022-07823_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Tynan 14; AER
Well Contractor Name FROM TO DESCRIPTION
2725-A —28 fL 40 ft. saprolite,pwr
ft. ft.
NC Well Contractor Certification Number 15:OUT_ER,CASWG for mulff-citsed'wctls OR h7NEY2 ifa licablaa',°
ETFROM TO DIAMETERi THICKNESS I MATERIAL
rt. rt. 'itr.
Company Name
WM0301221 / SIP-70003050 la.INNER CASING OR ThBING eathermalciosed-too
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U'IC.Counrv.State, I'ariance,etc.) 0 ft- 25 ff' 2 in. SCh40 PVC
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
Agricultural [3MunicipaVPublic
FROM TO DIAMETER SLOT SIZE THICKNESSMATERIAL
25 ft. 40 ft' 2 'n• 0.010 SCh40 Prepadced PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
Industrial/Commercial 13Residential Water Supply(shared) 18 G120iIT ;5,- -
:. .
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 20 ft• 23 ft bentonite pour
X Monitoring EIRecovery ft. ft.
Injection Well:
f1. ft.
Aquifer Recharge [3Groundwater Remediatiott
19.SAND/GRAVF,1PRCK itapplicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 1I StormwaterDrainage 23 fL 40 ft- #2 silica sand pour through augers
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRfLLlNG LW0G attach'3ddit(onallsheets iitcessar ".
FROM TO DESCRIPTION(color,hardness,soiltrock e, rain size,etc.)
Geothermal(Heatin 'Coolie Return) Other(es lain under 421 Remark) ft. ft.
See Consultant's Log
4.Date Well(s)Completed:8/2/2022 Well ID#TMW 4
ft. ft.
Sa.Well Location:
ft. ft.
Facility/Owner Name FacilitvID#(ifapplicable) ft. ft.
325 Rhyne Rd, Charlotte 28214 ft. ft.
Physical Address,City,and Zip ft. ft.
Mecklenburg
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.286485 N 80.968398 NV
/urrasz 8/11/2022
6.Is(are)the well(s) Permanent or Temporary SiLl"Itule of cel ' ed Well Contractor Date
By signing this Joan,1 hereby certih that the we s rims(iv`�'e�n°tI ucf, - dance
7.Is this a repair to an existing well: [3Yes or allo tvidr 15.9 NCAC 02C.0100 or ISA NCAC 02C.O rrycticat 9thn�ara�d 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#21 remarks section or on the back of this fame. m AUG
Ji G 2, 2, ZO Z,
23.Site diagra or additional well details: F'
8.For Geopr•obe/DPT or Closed-Loop Geothermal Wells having the same You may y?�#,i
use the back of this page to provide additional well Qsite details pF well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attachRtiirtlFpll ;cr�S rrll►ts 5'
drilled: bi�'J VBOG
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells listall depths ifdillzrent(example-3@t00'and2@1001 construction to the following:
10.Static water level below top of casing:-28 (ft.) Division of Water Resources,Information Processing Unit,
It'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b. For Infection Wells: It addition to sending the form to the address in 24a
auger above, also submit one copy of this form within 30 days of completion of well
12.Well 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(gprn) 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 the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Qualitv-Division of Water Resources Revised 2-22-2016