GW1-2022-07846_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVI HALL 14 WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
kA - 4459 ft. ft.ft. ft.
NC Well Contractor Certification Number 15.OUTER:CASING for multi-cased wells OR LWERi iCa `"lica6lE
GEOLOGIC EXPLORATION FROM To DIAMETER THICKNESS MATERIAL
ft. ft. ! in.
Company Name
16:,INNER CASING OR%TUBING` eo'thernialCclosed'too` =".,
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
P
Ldst all applicable well construction permits(i.e.UIC,County,Stale,Variance,ere.) 0.0 ft. 5.0 ft. 2,0 i 1°• $CH 40 PVC
3.Well Use(check well use): ft. ft. in.
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Water Supply Well: 17.SCREEN
FROM TO DIAMETER • SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft• 15.0 ft' 2.0 tn' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft• ft. in:
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ,. '
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft• 3.0 It' PORTIANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft.
19.:SAND/GRAVEL'PACK(if a licible
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENITMI THOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft- 15.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer '20.DRILLING LOG attach additional sheet"if:necess'a" x3 ''- ,. "
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO I DESCRIPTION color,hardness,soillrock type,grain size etc.
0.0 It. 1.0 ft. ASPHALT/GRAVEL
4.Date Well(s)Completed: 06/07/22 Well ID# MW-6 1.0 ft- 15.0 ft- SILTY CLAY
Sa.Well Location:
ft. ft.
KIMS CLEANERS ft. ft.
Facility/Owner Nam: Facility IDN(if applicable) ft. ft.
250 SOUTH MAIN STREET MOORESVILLE 28115 ft. ft.
Physical Address,City,and Zip ft. ft.
IREDELL z21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
350 34' 49.17" N 800 48' 54.17" W �� ����
06/15/22
Signature of Certified Well Contractor e
G.Is(are)the well(s): �Permaneot or ❑Temporary �' g"' I
By signing this farm,!hereby certify that the welt( wuaei �o a e with
7.Is this a repair to an existing well: ❑Yes or 15No 15A NCAC 02C.0100 or 15A NCAC 02C!0200 Well Construction Standards and I at a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the ojthis record has been provided to the well owner. n'�r
repair u Y tinder#21 remarks section or on the back ofthis form. ' 2022
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to pgVpJj* gW&pRrad nfo
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attac "eo9ges if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15.0 (ft.)
For multiple we/ls list a//depths ijderent(example-3(200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
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10.Static water level below top of casing: 7.0 (ft) 241. 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: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-Li op 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:
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13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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