GW1-2022-08627_Well Construction - GW1_20220826

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft; ft.
A - 4459 tt. fr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING' eothermal closed-loop)
2.Well Construction Permit#: FROM TO DLAMETER THICKNESS MATERIAL
List all applicable well construction permits(t.e.UIC,County,State,Variance,etc.) 0.0 ft. 5.0 ft. 2.0 1°' SCH 40 PVC
3.Well Use(check well use): tt. ft. in.
SCREEN;,"
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5.0 ft. 10.0 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
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 3.0 ft' PORTLANDBENTONrrE SLURRY
[NMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
El Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 ft. 10.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology El Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soi0rock type,gmin size,etc.
0.0 It. 5.0 11. FILL
4.Date Well(s)Completed: 05/26/22 Well ID# MW-3 5.0 ft. 10.0 ft. CLAY/ROCK
5a.Well Location: ft. ft.
GRIFFIN CLEANERS ft. ft.
Facility/Owner Name Facility lD#(if applicable) ft. fta:
105 DOVER STREET PINEVILLE 28134 rt. ft.
Physical Address,City,and Zip ft. ft.
MECKLENBURG 21.REMARKS''"`
County Parcel Identification No.(PIN) BENTONIfE SEAL-3.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 05' 07.44" N 800 53' 28.96" W 06/15/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or INNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
IJ'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.
repair under#21 remarks section or an the back of this form.
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 addiY�nai-l)Vell�QnsHatiofi�'Flo"`,
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attac�idilitioi3al•pages if$ecessary<
drilled: 10.o 24.SUBMITTAL INSTRUCTIONS AUG 2 2022
ti
9.Total well depth below land surface: (ft.) Submit this GW-1 within 30 days of well completion per the followin
For multiple wells list all depilhs ifd�erent(example-3 a 00'and 2 rei 100') lotion p;r'th7 o -`�(f f;y
DRY 24a. For All Wells: Original form to Division of Watgrjr4)iae"WtT!QC-(DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 276994617
If water level is above caring,use"+"
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy to DWR,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 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:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018