GW1-2022-08227_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information:
Mike Tynan 14:W)43ER
Well Contractor Name FROM TO DESCRIPT;IONf
2725-A —27 fL 34 ft. saprolite;pwr
n. ft.
NC Well Contractor Certification Number 15.OIITERCASING tfiifmulti-cased, ellij,OR fs1NER wa 'citable'
ETFROM TO DIAMETER THICKNESS MATERIAL
it. rt. In.
Company Name 16.CIVIVER CASII?tG;OR:TU)33NG eotherm8l cibsed-top
2.Well Construction Permit#:WM0301221 / SIP-70003050 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable troll construction permits(i.e.U1C,County,State, Munance,etc.) 0 ft- 119 ft. 2 rn Seh40 PVC
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17:'SCREFN`
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaVPublic 19 ft. 34 n• 2 in• 0.010 SCh40 PrepadtedPVC
Geothermal(Heating/Cooling Supply) E3Residential Water Supply(single) ft. ft. in
Indust ial/Commencial E3Residential Water Supply(shared) lIt fiROT1T .. .-- . ..
Ir'i ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT,
Non-Water Supply Well: 14 rr• 17 rr• bentonite pour
X Monitoring ®Recovery
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.5AND/GRAVELPACK ifa licabtc
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test j3StormwaterDrainage 17 ft- 32 ft. #2 silica sand pour through augers
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRIUItV`G7(3G attach:ndditiopal sheets if:necessa
FROM TO DESCRIPTION(color,hardness,soittrock type,groin size,etc.)
Geothermal(Heating/ oolin Return) 00ther(explain under q21 Rematl s) ft. ft.
See Consultant's Log
4.Date Well(s)Completed:8/2/2022 Well ID#TMW 3 ft. ft.
Sa.ti'ell Location:
ft. ft.
fL ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
325 Rhyne Rd, Charlotte 28214 rt. ft.
Physical Address,City,and Zip
n. ft.
-77
Mecklenburg "t2 REI
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutesAeconds or decimal degrees:
(if well field,one latflong is sutTicient) 22.Certification:
35.286031 N 80.969227 ��,
8/11/2022
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6.Is(are)the well(s) Permanent or X Temporrry SiLl'ature of Cei ied i\'cII Conhactor Date
By sgning this fomr, 1 hereby cerlifi that the eel isms(uzx�.*ms4mct0,,w dance
7.Is this a repair to an existingwell: Yes or X No with 15ANCAC 02C.0100 or 15.4 NCAC 02C.02 nst nSto�r n that a
li Uris is a repai 'll out drown tveconstnrc6o®nfornration m explain the nature ojthe copy o{this record has been provided to Ure well o na. � 6 `t
repair under 421 remarks section or on the back oJ'this form.
23.Site diagramor additional well details: P hJ f ? S 202Z
8.For Geopr•obe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide addrtional well site details or well
construction,only 1 GW-1 is needed. hndicate TOTAL NUMBER of wells construction details. You may also attach�tdlt# rle �t trey Urift
drilled: SUBMITTAL INSTRUCTIONS D,VQiBOG
9.Total well depth below land surface: 35 (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@.100�, construction to the fallowing:
10.Static water level below top of casing:-27 (ft.) Division of Water Resources,Information Processing Unit,
!/'water level is above cashes,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b. For Infection Wells: hr addition to sending the form to the address in 24a
auger above, also submit one copy of this form within 30 days of completion of well
12.auger,ell construction cable,
method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc..) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpnr) Method of test: 24c.For Water Supply& 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.
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Fenn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016