GW1-2022-07844_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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DAVI HALL 14.WATER ZONES
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FROM TO DESCRIPTION
Well Contactor Name ft. ft. `
A - 4459 ft. ft.
NC Well Contractor Certification Number I&OUTER CASING formultt-cased wells UR LINER if a 7ica61e
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. 1 in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loo"
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance.etc.) 0.0 ft- 15.0 ft. 2.0! "' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN`
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15.0 It- 30.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 10.0 ft' PORTLANDBENTONRE SLURRY
19Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK`ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 13.0 ft- 30.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING'LOG attach additional sheets if necessary):
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock rain size,etc.
0.0 ft 17.0 ft- CLAY
4.Date Well(s)Completed: 06/07/22 Well ID# MW-8 17.0 ft 30.0 ft- SILTY CLAY
Sa.Well Location: ft. ft. '
KIMS CLEANERS ft. ft.
Facility/Owner Name Facility I D#(if applicable) It. ft. I '
250 SOUTH MAIN STREET MOORESVILLE 28115 ft. ft.
Physical Address,City,and Zip
ft. ft.
IREDELL 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 10.0-13.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/long is sufficient) 22.Certification:
350 34' 49.17" N 800 48' 54.17" W
06/15/22
6.Is(are)the well(s): 291'ermanent or ❑Temporary Signature ofCertified Well Contactor Date¢¢
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By signing this form,I hereby certify that the well ce uh
7.Is this a repair to an existing well: ❑Yes or INNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 �S aV'an 121 copy
1f this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner. n�
repair under 921 remarks section or on the back ofthis form. A U r 2, ✓ 2022
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 additignal w
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may awwtl i i �i cessary.
drilled:
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30.0 1 (ft.)
Far multiple wells list all depths ifel fferent(example-3Q200'and 2 t@1001 Submit this GW-1 within 30 days of well completion per the following:
7.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If ivater level is above casing,use"+"
11.Borehole diameter: 8.0 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER j
24c.For Water Supply and Open-Lbob 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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018