GW1-2022-08617_Well Construction - GW1_20220822

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Mike Tynan 14.'WATER ZONF,S
Well Contractor Name FROM TO DESCRIPTION
2725-A -25 tt• 30 ft saprolite,pwr
NC Well Contractor Certification Number I5.OUTER CASINO(for inidt3-rnsed Nells OR:LRNE (tf,q' licatile
ETFROM TO DIAMETER THICKNESS MATERIAL
Company Name
WM 0301221 / SIP-70003050 16:,INNER cA5I1VG,OR TUBING ei hernial c]6sed Jod
2.Well Construction Permit#: FROM TO DIAMETFR THICKNESS ; MATERIAL
List all applicable well construction permits(i.e.UIC,Counw.State. l7ariance,eta) 0 ft. 15 ft' 2 rm SCh40 PVC
3.Well Use(check well use): fL ft. in.
Water Supply Well: .37.SCREEN Agricultural 13MunicipaUl'ublic .-
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
15 ft- 30 ft. 2 iry 0.010 Sch40 PVC
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. ft. in
btdusttialiCommereial [3Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
In
Supply Well: 10 tt• 13 rt• bentonite pour
X Monitoring Recovery ft. ft.
Injection Well: ft. ft.
.Aquifer Recharge Groundwater Remediation
1ND
Aquifer Storage and Recovery Salinity$airier 19.S IGRAVEL,FACK-if aWal le FROM TO MATERIAL EMPLACEMENT METHOD
.Aquifer Test [3Stormwater Drainage 13 ft- 30 ft. #2 silica sand pour through augers
Experimental Technology Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20.1)RILLINGIAG a`ttacliariititiotiai•sheets if necessq
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
Geothermal(Hearin Coolin Return) Other(explain under#21 Remarks) ft. tt.
See Consultant's Log
4.Date Well(s)Completed:8/1/2022 Well ID#TMW 2 ft. ft.
Sa.Well Location:
ft. ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
325 Rhyne Rd, Charlotte 28214
Physical Address,City,and Zip ft. ft.
Mecklenburg 21.REMAMCS
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:
35.287318 N 80.970099 N,
8/11/2022
6.Is(are)the well(s)OPermanent or IDTemporary 5iLl"Itule ofCei ' ed Well Contractor Date
6y signing this form, 1 hereby cerfifi that the well(s)was(were)constnmted in accordance
7.Is this a repair to an existing well: ®Yes or allo with ISA NCAC 02C.0100 or 15.4 NCAC 02C.0200!Fell Construction Standards and that a
Ifdris is a repair fill out known well constntedon information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site dia ram or additional well detail � v"�
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide`a1it WzkveB site r well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additi �IiRagrs.f essa
drilled: SUBMITTAL INSTRUCTIONS 41 , !! J 0NY
9.Total well depth below land surface: 30 (ftJ 24a. For All Wells: Submit this fonifIN51r ff c� r�^���trifi��f well
Formultiple wells list all depths ifdi,Jlerent(example-3@,100'and 20.100) construction to the following: `
10.Static water level below top of casing:-25 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use "+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.5 (in.) 24b.For Injection Wells: In 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.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: 1636 Mail Service CIenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply& Iniection 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 2-;2-2016