GW1-2023-00797_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES w.
Well Contractor Name FROM TO DESCRIPTION
fr. fr.
A - 4226 ft. ft. I
NC Well Contractor Certification Number e 15.OUTER CASING foe multi-cased'wells OR LINER ifa licable
� ,'rr"',' '�. r`?^`' FROM TO DIAMETER THIC[NESS MATERIAL
GEOLOGIC EXPLORATION '� _ ,,��u d , ft. ft. in.
Company Name p��
JHIV 1 2 2023 16.INNER CASING ORTUBINC eothermalclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC, ouny Staler-(!riancg.-elc).,; t 0.0 fr• rJ$.O ft- 1.0 '"' SCH 40 PVC
�fl _4c-,....0
3.Well Use(check well use): `�.}.'i3'31 i 0.0 fr. 38.0 ft• 1.0 '"' SCH 40 PVC
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agric.Liltural ❑Municipal/Public 58.01" 60.0 It' 1.0 in-' .010 SCH 40 PVC
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 38.0 ft. 40.0 1" 1.0 in. .010 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Itri ation ❑Wel Is>100,000 GPD FROM TO MATERIAL EMPLACEM ENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 35.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
lA.SAND/GRAVEL PACK if a, licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 57.0 ft. 60.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control 37.0 ft- 40.0 ft. 20-40 FINE SILICA SAND
❑Geothenmal(Closed Loop) ❑Tracer 20.DRILLING LOG'attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain sin,etc.
0.0 ft. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 11/22/22 well ID# BS-27-B/A 1.0 ft- 22.0 ft- BROWN CLAY
5a.Well Location: 22.0 ft' 50.0 ft' BROWN SILT
GLIDDEN COMPANY 50.0 ft. 60.0 ft. GRAY SILTY PWR
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3926 GLENWOOD DRIVE CHARLOTTE 28208 rt. ft.
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG zL REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-40.0-57.0 FEET&35.0-37.0 FEET
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***NESTED WELLS
(if well field,one W/long is sufficient) 22.Certification:
350 15' 00.27" N 800 53' 06.04" W Alm A,,,,�..-�- 11/30/22
6.Is(are)the well(s)• (EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the we//(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 2lNo 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 of this record has been provided to the well owner.
repair order#21 reoarks section or on the back of this fore.
23.Site diagram or additional well,details:
S.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-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 60.0/40.0 (ft.)
For multiple wells list al/depths/fdii ferent(example-3@200'and 2 a 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-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
Permit Program,1611 MSC,Raleigli,NC 27699-1 61 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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