GW1-2022-07845_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVI HALL 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4459 ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR,LINER iC8 livable'
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. fit C in.
Company Name
16."INNER CASING':OR TUBING fieorhermall dosed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UAC,County,State,Variance,etc.) 0•0 ft. 10.0 ft. 2.0 j in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 19:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft• 25.0 ft• 2.0 'nj .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 778GROUT .s
❑bTl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 5.0 ft' PORTLAND'BENTONITE SLURRY
(Monitoring ❑Recovery R. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 8.0 ft 25.0 fr. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. I ft.
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING LOG attach additionilsheets irTecessa'"
❑Geothermal(Heating/Cooling Return) []Other(explain tinder#21 Remarks) FROM To I DESCRIPTION color,hardy soil/rock VIM grain size etc.
0.0 ft. 1.0 ft. ASPHALT/GRAVEL
4.Date Wells)Completed: 06/07/22 Well ID# MW-7 1.0 fit 25.0 ft- SILTY CLAY
Sa.Well Location:
ft. ft.
KIMS CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
250 SOUTH MAIN STREET MOORESVILLE 28115 ft. ft.
Physical Address,City,and Zip ft. ft
IRED ELL 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-5.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 34' 49.17" N 800 48' 54.17" W ��,,� e4/�e
06/15/22
6.Is(are)the well(s): I!gPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,/hereby certify that the well(s)was ry c p+rc rh
7.Is this a repair to an existing well: ❑Yes or CSNo 15A NCAC 02C.0100 or 15A NCAC 02C'. Nell c IZS t9 t t co
If this is a repair,fill out known well construction information and explain the nature of the ofihis record has been provided to the well owner.
repair wader#21 remarks section or on the back of this form.
23.Site diagram or additional well details: Q,U r 2, 2 211n
22
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may alsgi( dt gtipt $a s serElS6aE].
drilled: 24.SUBMITTAL INSTRUCTIONS rJb#d( f3CJC'
9.Total well depth below land surface: 25.0 (tt.
For multiple wells list all depths ifdiljerent(example-3@200'and tea 100') ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 7•0 (ft.) 24s. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
$.0 24b.For Injection Wells:Co D
I1.Borehole diameter: (in.) Copy to WR,Underground Injection Control(IUC)
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 departm intof the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roduciu 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 j Revised 6-6-2018