GW1-2022-07825_Well Construction - GW1_20220822

1
WELL CONSTRUCTION RECORD(GW-1) I For Internal Use Only:
1.Well Contractor Information:
Mike Tynan 14.)'FA:TER7011 3
Well Contractor Name FROM TO DESCRIPTION
2725-A —27 ff• 35 saprolite,pwr
ft. ft.
NC Well Contractor Certification Number 15.UUTER C ASIiNO(for"'ult1-caii4ii7Wi) LINTER if i ikable.
ETFROM TO DIAMETER THICKNESS MATERIAL
rt. ft. in.
Company Name A TIVIVERCASING`O17TUBTNCr eothermat:cltised-loo' i'
WM0301221 / SIP-70003050 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: i
List all applicable well construction permits(i.e. UIC,Counn.State, lZariance,etc.) 0 ft. 20 ft. 2 rm Seh40 PVC
3.Well Use(check well use): ft. ft. in
�Yater Supply Well: 37.SCREEN
FROM TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
Agricultural [3MunicipaVPublic 20 ft- 35 ft- 2 i" 1 0.010 Sch40 I Prepadced PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. f, in
Industrial/Commercial Residential Water Supply(shared) YS,GROIiT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD At AMOUNT
Non-Water Supply Well: 15 ft. 18 rL bentonite pour
X Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SANDIGRAVII.-PACK if applicalile --
Aquifer Storage and Recovery Salinity Barrier bROM TO MATERIAL EN[PLACEMENT METHOD
Aquifer Test j3Stormwater Drainage 18 ft. 35 ft• #2 silica sand pour through augers
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20 DRfJjANG1,04 attach additibilal-s bet ts`if necessa •
FRONI TO DESCRIPTION color,hardness,soitlrock t ape,g rain size,etc.)
Geothermal(Heating/ ocilin Return) 00ther(explain under 421 RernadsLj ft. ft.
See Consultant's Log
4.Date Well(s)Completed:8/2/2022 Well ID#TM V V�/��—5 tt ft.
Sa.Well Location: ft. ft.
ft. ft.
�.-„ � Vie,..
Facility/Owner Name Facility ID#(if applicable) ft. ft' t s I,N
325 Rhyne Rd, Charlotte 28214
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:
35.286123 N 80.967700 «,
74,E / 8/11/2022
6.Is(are)the weli(s)(31'ermanent or XOTemperary SiLmature of'CoVld
Well Contractor Date
By signing this form,1 hereby certifi that the uell(s)was(were)constnrcted in accordance
7.Is this a repair io an existing well: []Yes or XONo with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair:fill out known well comtniction 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 o}'this fort.
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-1 is needed. indicate TOTAL NLJMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 38 (ft-) 24a. For All Wells: Submit this form nvithiu 30 days of completion of well
For multiple wells list all depths if diJjarent(example-3@200'and 2ra;100) construction to the following:
10.Static water level below top of casing:—27 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above caring,use "+" 1617 Mail Service.Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b. For Infection Wells: hi addition to sending the form to the address ill 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 2 7699-1 636
13a.Yield(gpm) Method of test: 24c.For Water Supply& Infection 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 constnuctiory to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of En ironmental Quality-Division of Water Resources Revised 2-22-2016