GW1-2021-07884_Well Construction - GW1_20211102

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WELL.CONSTRUCTION RECORD(GA-11 For Internal Use Only:
1.Well Contractor Information:nt
Daniel Summers 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 14 ft 24 ft.
2579-A ft &
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
Carolina Soil Investigations, LLC FROM TO DIAM ETERI THICKNESS MATERIAL
0 ft 14 ft 2 m. 1 Soh 40 PVC
Company Name
IG.INNER CASING OR TUBING eothermatclosed-loo
2.Well Construction Permit#: DEQ#WM030115-and-Meck#7000293 FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER :SLOT SIZE THICKNESS MATERIAL
Agricultural rIMunicipal/Public 14 ft 24 rt, 2 'n' 010 SCh 40 PVC
17-1 Geothermal(Heating/Cooling Supply) [ Residential Water Supply(single) tt ft in
0 Industrial/Commercial E]Residential Water Supply(shared)
18.GROUT
13 Irrigation Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 5 ft. portland mix&Pour
JZ Monitoring Recovery 5 ft 12 ft- bentonite tremie
Injection Well: ft. ft. i
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL`PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
_Aquifer Test Stormwater Drainage 12 ft 24 ft. 10/30 silica sand tremle
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG attach additional'sheets if necessary)
Geothermal(Heating/Cooling Coolin Return) FROM TO DESCRIPTION color,hardness soil/rock rain Size etc.
( g/ g ) Other(explain under#21 Remarks) 0 ft. 24 ft brown silt loam/brown silty clay/saprolite
4.Date Well(s)Completed:10/21/21 Well ID# MW-1 MW-3 ft. fL
5a.Well Location: ft. ft 1,a'
Griffin Oil Company ft ft
Facility/Owner Name Facility ID#(ifapplicable) ft ft N n U
7922 Penny Place Lane Mint Hill, NC ft ft.
p
Physical Address,City,and Zip ft ft. Mi Ing Unit
DIAIR
Meck 21.REMARKS ,-
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Ccrta on:
35.17877 N -80.64753 W 10/21/21
6.Is(are)the well(s):E]Permanent or O Temporary Signature of 'ertified Well ontractor Date
By.signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or El No with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
1f this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 remarks section or on 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 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: 2
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2@24 (ft.)
For multiple wells list all depths;f different(example-3@200'and 1@100') 24a. For All Wells: Submit this'form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 18 (ft.)
If water level is above casing,use"+" Division of Water Resources,Information Processing Unit,
$„ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b. For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: auger above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SuoDly& Infection 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 6-6-2018