GW1-2023-00807_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GM-1) For Internal Use Only: ;p
1.Well Contractor Information: I
BRIAN THOMAS 14.WATER ZONES' I
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Wells)OR LINER if a licable GEOLOGIC EXPLORATION G n FROM ft TO ft DIAMETER t� THICKNESS MATERIAL
Company Name JA1 1 2 J
16.INNER CASING OR TUIIING eothermal closed-too
2.Well Construction Permit#: �.;.-.r r,^;t'.'It.il,. FROM TO DIAMETER THICKNESS MATERIAL
List a!l applicable well construction peroits(i.e.(/(G J oinilj{S�gle..Yarjpuae,etc.) 0.0 ft. 20.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): rt. ft. in•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 ft. 40.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fr. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
OIrri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 5.0 ft. PORTLANDaENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test OStormwater Drainage 17.0 tt 40.0 tr' 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 cold+•,hardness,soilfrocl e, iain size,etc.)
0.0 ft. 1.0 ft. ASPHALT/CONCRETE/GRAVEL
4.Date Well(s)Completed: 1 0/20/22 Well ID# PZ-1 1.0 tr 9.0 ft RED SILTY SANDY CLAY
Sa.Well Location: 9.0 fr' 21.0 ft' RED SILT
EASTWAY SHOPPING CENTER 21.0 ft 40.0 ft TAN SILTY SAND
Facility/Owner Name Facility ID4(ifapplicable)
1314 CENTRAL AVENUE CHARLOTTE 28205 fr. ft.
Physical Address,City,and Zip ft. ft.
MECKLENBURG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-5.0-17.0 FEET
***PIEZOMETER***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 13' 08.51" N 800 48' 56.56" W - �' '`- 10/24/22
6.Is(are)the well(s): OPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this fbrnn,1 hereby certify that the well(s)u•as(were)conslrucled in accordance trill)
7.Is this a repair to an existing well: ❑Yes Or 29No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Siandarch and that a copy
1J*duv is a repair,fi/l out known well construction infornnaion and explain the nature of the ofthis•record has been provided to the well owner.
repair under r2l remarks section or on the back of this ford.
23.Site diagram or additional well details:
8.For Gcoprobc/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: 40.0 (ft.)
Ivor nuthiplc twe/Ls li.ri all depihs ifdifferent(example-3 rer200'and 2@/00') Submit this GW-1 within 30 days of well completion per the following:
18.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level iglus top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/flrater level is above casing,use"+"
11.Borehole diameter: 6.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
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 iover 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disipfection type: Amount:
i
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018