GW1-2022-08221_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
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Mike Tynan 14:WATE122ONE3
Well Contractor Name FROM TO DESCRIPTION
2725_A —25 ft• 40 saprolite
ft. ft.
NC Well Contractor Certification Number 15,`QUTER=CA5INIG Corn ulti cased:icells.UR I,LNFIt.fFa" ' icable);
ETFROM TO DIAMETER THICKNESS MATERIAL
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Company Name
WM 0301221 / SIP-70003050 16:' vNz cASIraG oxc; zlcctner��helos,a-Iao
2.Well Construction Permit##: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernrils(i.e.UIC,Count'.State. Variance,etc.) 0 ft. 25 ft. 2 rn Seh40 PVC
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17FSCREET z�'_ e,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipai/Public 25 ft- 40 rt- 2 rn 1 0.010 Sc1140 Prepacked PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft is
Industrial/Commercial Residential Water Supply(shared)
Iri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNTS
Non-Water Supply Well: 20 ft• 23 ft• bentonite pour
x Monitoring ®Recovery
Injection Well: -
rt.
Aquifer Recharge ®Groundwater Remediation
49 SANDIG,RAVEL PACK'1Ca "Iitable '
Aquifer Storage and Recovery [3Sahnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3StormvvaterDrainage 23 ft- 40 ft• #2 silica sand pour through augers
Experimental Technology 13SubsidenceControl ft ft.
Geothermal(Closed Loop) Q Tracer 20.)?RII,I IIVGI Ois attatfiadtlitio''tsai shee'fs tf necessa'
FROM TO DESCRIPTION color,hardness,soiVrock type, -rain size,etc.)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remark) ft ft
See Consultant's Log
4.Date Well(s)Completed:8/3/2022 Weil ID#TMW 6 ft ft.
ft. n.
5a.Well Location:
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft Alh .: v
325 Rhyne Rd, Charlotte 28214 ft.
Physical Address,City,and Zip ft. ft. �
Mecklenburg 21•,aE�s
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient)
22.Certification:
35.284559 N 80.967923 N;, � 1
8/11/2022
6.Is(are)the well(s)OPermanent or XOTemporary Signature of Cer Vled Well Connactor Date
By signing this faint 1 hereby certi/y that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 iI ell Consbuction Standards and that a
Ifihis is a repair,fill out known well constnuction information and explain the natn78 of the cop),of this record has been pnvided to the well owner.
repair under#21 remarks section or on the back of tl ris farm.
23.Site diagram or additional well details:
8.For Geopr•obe/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 NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 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
Formultiple wells list all depths if dijjerent(example-30a,700'and 2@100) construction to the following:
10.Static water level below top of casing:—25 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,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 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(gp►n) Method of test: 24c.For Water Supply& Lniection 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 Quality-Division of Water Resources Revised 2-22-2016