GW1-2023-00806_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES u '
Well Contractor Name FROM TO DESCRIPTION
A - 3098 ..,na
NC Well Contractor Certification Numbers
(� 15.OUTER CASING for multi-cased wells 0 1 LINER ifa ilicable
GEOLOGIC EXPLORATION JAN fl v 2QZ3 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING i cothermal closed-loop)
2.Well Construction Permit#: WM030124�'_ t (J «yy FROM TO DIAMETER THICKNESS MATERIAL
List all applicable uvell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 27.0 ft' 2.0 in, SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 27.0 fr. 32.0 ft. 2.0 1°' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 220 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL
fr.
PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL I EMPLACEMENTAIETHOD
❑Aquifer Test ❑Stormwater Drainage 25.0 ft• 32.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soittmck type,grain size,etc.
0.0 ft. 11.0 ft. RED/ORANGE CLAY
4.Date Well(s)Completed: 11/1$/22 Well ID# MW-25I 11,0 ft• 20.0 ft• BROWN SILT
Sa.Well Location: 20.0 fr' 30.0 ft' BROWN PWR
CHARLOTTE DOUGLAS AIRPORT 30.0 ft• 32.0 ft• GRAY PWR
-- Facility/Owner Name - Facility ID#(if applicable) ft. ft.
R.0.W.EATONTON STREET/NEWBERRY STREET CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip ft. ft.
M EC KLEN BU RG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-22.0-25.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 13' 53.97" N 800 55' 48.96" W 12/01/22
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the trel/(s)Iras•(were)constructed in accordance trirh
7.Is this a repair to an existing well: ❑Yes Or MNo I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
lfthi.s is a repair,fill out known well construction infbrnialion and explain the nature of the oflhis record has been provided to the Ire/I owner.
repair antler P21 remarks section or on the back oflhis 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 I GW-1 is needed. Indicate TOTAL NUMBER ofwells (add'See Over'in Remarks Box).You may also attach additional pages ifnecessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 32.0 (ft.)
For un itiple hells list al/depths ifdierent(example-3@200'and 2@I00')10. Submit this GW-1 within 30 days of well completion per the following:
6.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
1f/'mater level is above casing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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: AUGER 1
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
I3a.Yield(gpm) Method of test:
Permit Program,1611 MSC,Raleigh,NC 27699-1611
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13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018