GW1-2021-05773_Well Construction - GW1_20211015

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells F
1.Well Contractor Information:
Sam Bowers "� ?� ' _ 14.4WATRZONES� .. . � F s
.<°y �N� FROM I TO DESCRIPTION
Well Contractor Name ft. ft.
INI
3220 A ��Z �V i
>S°
NC Well Contractor Certification Number r' , ;f ..15.OUTER CASING-formlilh cased«ells'ORLINERr d i 7tc"ilile �
` FROM TO DIAMETER THICKNESS MATERIAL
Geological Resources, Inc. ; ft. ft. in.
Company Name 16.INNER:CASINGIOR-TUBING -eo1Le"r'mal"closed
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit th 0 tt. 5 ft. 2" in. sch 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN 4 a�
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 fa 20 ft. 2 in., 0.010 sch 40 PVC
❑Geothermal(Heating/CoolingSupply) ❑Residential Water Supply ft. ft. i�•
PP Y) Pp Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) =18.GROUP : I I'd
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 2 ft- Cement
Non-Water Supply Well:
EMonitoring ❑Recovery 2 ft. 4 tt. Bentoriite
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation :19:SA1D7GR1V-EIPACK=tf;a"liftable _t, ,�?
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 4 ft. 20 tt. iSand
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ,•, 4.._
20.-DRIE'Ll G=LOG,affachia0dthonil sheefstif,necessa"
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness,soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 2 ft. Topsoil
07/28/21 MW-3 2 ft. 5 ft. Light brown silt
4.Date Well(s)Completed: Well ID#
5 ft. 8 ft. Tan sandy silt
5a.Well Location:
8 ft- 12 ft. Light brown silty clay
Baker Site n/a 12 ft. 20 ft. Brown silty sand
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
204 West 18th Street, Kannapolis, NC ft. ft.
Physical Address,City,and Zip
Rowan 28081
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification
(if well field,one]at/long is sufficient)
35.518971 N 80.616553 W 08/04/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,1 hereby certify'that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction infonnalion and explain the nature of the
repair under 921 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-waler supply wells ONLY with the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 12.86 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
�� 1
11.Borehole diameter: 6 (in.) 24b. For Infection Wells ONLY;: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
6" Solid Stem Auger
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: 16316 Mail Service iCenter,Raleigh,NC 27699-1636
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013