GW1-2022-07821_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
DAVID HALL 14.WATEWZONES
FROM TO DESCRn'TION
Well Contractor Name ft.
A - 4459 ft.ft. t.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cos td wells OR LINER ifia"°licable i
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. 1L in.
Company Name
16.,INNER CASING OR TUBING n eofhermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0•0 ft. 2.0 ft- 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. 1 in
Water Supply Well: '47.,SCREEN :,.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL,
❑Agricultural ❑Municipal/Public 2 0 ft' 12.0 ft 2.0 1°' O10 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. it..
❑Industrial/Commercial ❑Residential Water Supply(shared) Is GRouT,
❑Irrl anon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 1.0 ft. PORTLANDBENTONRE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well: ft. tL
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 1.5 ft. 12.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.=DRILLING10G attach additioiialfsheets+if�oecessa' 'z r
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soiltrock type rain size,etc.
0.0 ft. 1.0 ft. GRAVEL
4.Date Well(s)Completed: 05/20/22 well rD# MW-10 1.0 ft. 6.0 ft. CLAY
5a.Well Location: 6.0 ft• 12.0 It' SANDY SILT
TRANSMONTAIGNE FUEL ft. ft.
Facility/Owner Name FacditylD#(if applicable) ft. ft. I
7615 OLD MT HOLLY ROAD CHARLOTTE 28214 ft. ft.
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG •41'REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 1.0-1.5 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
350 16' 43.97" N 800 56' 10.29" W 06/15/22
6.Is(are)the well(s): Permanent or ❑Temporary Signature of Certified well Contractor ' �, f ;D8t€
"'h t�
By signing this form,I hereby certify thailhe s ,)duos$i efe�-M rdance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owne-AUG
A I(� �, 2�2�
repair under#21 remarks section or on the back of this form. J
23.Site diagram or additional well details: to
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page tq�gvW&43dtt?6fiTa <tl'e�4;9sWt%n info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also a159 tiQ&Q&i pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12.0 (ft.
For multiple wells list all depths ifdii different(example-3@200'and 2@100') ) Submit this GW-1 within 30 days!of well completion per the following:
10.Static water level below top of casing: 7.0 (ft) 24a. For All Wells: Original form:to Division of Water Resources (DWR),
If water level is above casing,use"+ Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
$.0 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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 27699-1 61 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-
Division of Water Resources, Revised 6-6 2018