GW1-2023-00792_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES ` fi
Well Contractor Name FROM TO DESCRIPTION
4
A - 4226 ft. ft.
.l_
_.9, ) ft. ft. ,! -. 1
NC Well Contractor Certification Number ; i d1,
'��,>% 15.OUTER CASING for uulti-casedwells OR LINER ifa"tlicable
GEOLOGIC EXPLORATION FROM TO DIAMETER I THICKNESS MATERIAL
9'1 ft. ft. I in.
Company Name '.16.INNER CASING OR TUBING eottiermal closed-loop)
2.Well Construction Permit#: Ul,+'.FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Codt ,''3ia'te,�Vp iax�c .'�tG L; 0.0 ft' 87 0 ft- 1.0 in. SCH 40 PVC
3.Well Use(check well use): fr. fr. in.
Water Supply Well: 17.SCREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 87.0 ft' 89.0 ft. 1.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1g.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 84.0 ft- PORTLANDBENTONITE SLURRY
Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a licabte)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 86.0 ft• 890 tt. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20..DRILLING'LOG attach additional sheets if necessary)
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❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilh•ock type, inin size,etc.)
0.0 fr 1.0 It. GRASS/TOPSOIL
4.Date Well(s)Completed: 10/25/22 Well ID# BS-42C 1.0 ft. 24.0 ft• BROWN CLAY
Sa.Well Location: 24.0 ft' 67.0 ft' BROWN SILT
GLIDDEN COMPANY 67.0 ft- 89.0 rt. GRAY SILTY'PWR
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3926 GLENWOOD DRIVE CHARLOTTE 28208
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-84.0-86.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wilting is sufficient) 22.Certification:
35° 15' 00.12" N 800 53' 07.44" W 11/30/22
6.Is(are)the well(s): [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing(his form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [5No LiA NCAC 02C.0100 or i5A NCAC 02C.0200 Well Construction Standards and that a cope
If this is a repair•fill out known the//construction information and explain the nature of the ofthis record has been provided to the sell o,Pner.
repair under#21 remarks section or on the back ofthis 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 construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 89.0 (ft.)
For multiple hells list all depths ifdierent(example-3 a 200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
40•0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 8.0 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SONIC
24c.For Water Supply and Open-Loon Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
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FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over.100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh'NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-20IS
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