GW1-2023-00814_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 11
1.Well Contractor Information: t
KENNY SARGENT 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
A - 4226
ft. ft.
NC Well Contractor Certification Number P
c ! 15.OUTER CASING for multi-caLd'wells OR LINER if a licable
GEOLOGIC EXPLORATION z.,p r �' ,'�'�� FROM TO DIAMETER THICKNESS MATERIAL
.-. ft. I ft. I i in.
Company Name J A N j 2 9 L�'Z'3
16.INNER CASING OR TUBING euthermal closed-loop)
2.WCII Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable irell construction permits(i.e.UIC,ioun ,Stp(e,1!aria»eC'L'lc;)� 1319• ft. ft. in.
4 1, ,•.Y,� � 0.0 97.0 1.0 � SCH40 PVC
3.Well Use(check well use): 'IV 1�J�') ft. ft. in.
17.SC
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 97.0 f" 99.0 ft. 1.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT ,
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 94.0 ft- PORTLANDBENTONnE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 96.0 ft 99.0 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,soil/rock type,grain size,etc.
0.0 ft- 1.0 ft. GRASS/IOPSOIL
4.Date Well(s)Completed: 11/03/22 Well ID# BS-39C 1.0 ft. 22.0 ft. BROWN CLAY
5a.Well Location: 22.0 ft' 71.0 f" BROWN SILT
GLIDDEN COMPANY 71.0 ft 99.0 ft- GRAY SILTY PWR
Facility/Owner Name Facility ID#(if applicable) ft. ft. }
3926 GLENWOOD DRIVE CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip
M ECKLEN BU RG 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-94.0-96.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 15' 01.42" N 800 53' 06.45" W 11/30/22
6.Is(are)the well(s)• 291'ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify ilia'Me trell(s)was(were)constructed in accordance uvith
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this•is a repair,Jill out knorn well construction information and explain the nature oJ'the of this record has been provided to the Lrell ou ner.
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 I GW-I 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: 99.0 (ft.)
For multiple wells list all depths ifelifferent(example-3 a 00'and 2@100) Submit this GW-1 within 3l)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 nrater 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-Lb op Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department•of the county where installed
i
FOR WATER SUPPLY WELLS ONLY:
24d.For Water Wells producin> over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,INC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
i
13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018