GW1-2021-02463_Well Construction - GW1_20210521

�'"�t5rint;For F
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information: A.}-w
Terry White 4��tr
I?-'��._.a 14:WATER ZONES.
Well Contractor Name FROM To DESCRIPTION
fll l 2021
3287-A �`�AY 10 ft. 11 ft.
�i ft. ft.
NC Well Contractor Certification Number mej' t�ulll
,� �:0�}'j CC- � I5.OUTER CASING for multi-cased wells OR LINER a tieable
I ET 'C1£`oit 1 D t; ^i"�I) FROM TO DIAMETER TRiCKNE.CS MATERIAL
ft. fL in.
Company Name
WM0301124 SIPS- 70002869 16.INNER CASING ORTUB1Nc(geothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) 0 ft. 1 ft' 1 ro' I SCh40 pVC
3.Well Use(check well use): ft. ft' rm
Water Supply Well: 17 SCREEN ,
FROM TO DIAMETER ! SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaYNblic 1 ft- 11 ft- 1 1D 0.010 srh40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in
lndustriaUCommercial Residential Water Supply(shared) 18.GROUT
lrri ation FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 0.5 ft- Bentohite poured/1LB
x,Monitoring ORecovery
Injection Well: -
fL ft.
Aquifer Recharge ElGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery aSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [:)Stormwater Drainage 0.5 ft- 11 ft- #2 Sand Poured
Experimental Technology Subsidence Control ft. fL
_ Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)-
Geothermal(Heating/Cooling Return) 130ther(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,wiUrwk a gnin size,etc.
ft. If. See Consultant Log
4.Date Well(s)Completed:5/7/2021 well TD#TMW-1 ft. fL
5a.Well Location: ft. fL
7-Eleven #35578 ft. fL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5200 Piper Station Dr. Charlotte 28277 ft ft-
Physical Address,City,and Zip ft. ft.
Mecklenburg 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.Certification:
35 03 39 80 48 45
N w j � 5/14/2021
6.Ts(are)the well(s)[31'ermanent or ElTemporary Sig al rra Ceniiiad'Wc[l-Contractor Date
By signing this form,1 hereby certify that the wrll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or _XE No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If 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#21 remarks section or an the hack oJ'this farm.
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 Lto 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:one SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 1 (fL) 24a. For All Wells: Submit this',form within 30 days of complction of wcll
For multiple we1Ls list all depths if different(example-3@200'mud 2@100) construction to the following:
10.Static water level below top of casing:10 OIL) Division of Water Resources,Information Processing Unit,
#'water level&above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:2 1/4 011.) 24b.For lniection Wells: In addition to sending the form to the address in 24a
Direct Push 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.) l 41
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 Supply&Injection 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 G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016