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Home My WebLink AboutGW1--01256_Well Construction - GW1_20240229 • I( Print Form WELL CONSTRUCTION RECORD(GW-1) . '.Fdr Internal Use Only: " • • 1.Well Contractor Information: . ,' ' Dan.ielSummers , ' 14.WATER ZONES • ' ' FROM .' TO 'DESCRIPTION ' . . . . . . ' • Well Contractor Name y • 10 fc.: 20 fc• ` 2579-A • ft., tr I NC Well Contractor Certification Number . 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable) Carolina:S:oil.Investigations, LLC FROM. TO. ' • DIAMETER :' THICKNESS . MATERIAL .. . 0 ft' • ..I0 . •ft*v. . 2 i in, sch 40 PVC Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) 2.Well Construction Petmit#d• Meck SIP:70003179" 'DEQ:WM0301343 " FROM . ' TO ' ' DIAMETER . THICKNESS ' •MATERIAL ' ' List all applicable well construction permits(i.e.UIC,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 0 Agricultural ' . lavlunicipal/Public. .10 ft. : • 20 ft : . 2 :"1°•I ' -010. sch 40 pvc • ' '0 Geothermal(Heating/Cooling Supply) `El Residential Water Supply(single). " tt,.. : ft, m.`, . In Industrial/Commercial .0 Residential.Water Supply(shared) .18.GROUT 0Irrigation' • .Q Wells>100,000GPD FROM TO : 'MATERIAL EMPLACEMENT METHOD&AMOUNT: Non-Water Supply Well: - 0 ft•. . 5 ft. portland mix&Pour • Monitoring El Recovery ' 5.. ti. 8 ftr. bentonite tremie •Injection Well: ft.." ft: 0 Aquifer Recharge' . 0 GroundwaterRemediation • 19.SAND/GRAVEL PACK(if applicable) . . .0 Aquifer Storage and Recovery .0 Salinity Barrier .FROM . .TO .' - ' MATERIAL • EMPLACEMENT.METHOD . Aquifer Test • 'Q Stormwater Drainage ' ' 8 .to. 20' ft..: . 10/30 Silica sand. tremie D Experimental Technology . ' ®Subsidence Control ft.' ft. D.Geothenttal(Closed Loop) .. . .D.Tracer' .' • 20.DRILLING LOG(attach additional sheets if necessary) FROM TO - .DESCRIPTION(color,hardness,soil/rock type:grain size,etc.) ' -71 Geothermal(Heating/Cooling Return) . Other(explain under#21-Remarks)- - 0 ft*: : .20: ft brown'silt loam/brown silty clay/saprolite • ' 4.Date.Well(s)Completed:02-15-24 , Well ID# Mw - - ft. ft.: 5a.Well Location: • • - ft. ft � �t 94 • ." ft,. . .ft. `� r r��/ >' y ^1 ) Facility/Owner Name Facility ID#(if applicable) it: •ft:. �r 4.- • 10207'North Tryon'St Charlotte,.NC' ft..-. ft. . • Physical Address,City,and Zip. • .. .. • . - " . .Mi ,',�,e,, a... a .. .. - u Meck - ft. ft.. . ra9,,Q. ^? ,�. UA.. _ 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) • .a:Certifieaiton: -- . 35:32452 N 80,73605 W n 1 ' (L ; -02-15-24 6.Is(are)the well(s):X®Permanent or Temporary Signature of Certified Well Contractor ; Date 7.Is this a repair to an existing well: Yes. or No By'signing this'form,I hereby certt&That the well(s)was(were)constructed in accordance • 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 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: : . 1 : SUBMITTAL INSTRUCTIONS 9.Total well'depth below land surface: 20' • (ft.) , For multiple wells list all depths if different(example-3 @1 00'and 2@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: . . . (ft.) • Ifwater.level is above casing,use"+" Division-of Water Resources,Information Processing Unit, an 1617 Mail Service Center,Raleigh,NC 27699-1617 11..Borehole diameter: (in:) 10 • 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 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 GW-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised 6-6-2018.