GW1-2023-00848_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATERZONES
Well Contractor Name FROM ft TO ft DESCRIPTION
A - 4226
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a tlicablc
n- -
GEOLOGIC EXPLORATION ~ 'z.r FROM TO DIAMETER' THICKNESS MATERIAL
ft. ft. in.
Company Name
R 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: J A N S r 2Q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC,County,State,Variance,etc.)• 0.0 ft. 97.0 ft. 1.0 t"' SCH 40 PVC
3.Well Use check well use): r-,c ;.•• ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 97.0 ft' 99.0 ft. 1.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 94.0 ft' PORTLANDBENTONITE SLURRY
29Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a t tlicablc
El 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 921 Remarks) FROM TO DESCRIPTION color,hardness,soill rock type,gnain size,etc.)
0.0 ft. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 11/08/22 Well ID# BS-35C 1.0 ft• 22.0 ft• BROWN CLAY
5a.Well Location: 22.0 ft. 71 0 ft' BROWN SILT
GLIDDEN COMPANY 71.0 fr. 990 fr. GRAY SILTY PWR
---- Facility/OwnerNarne - - Facility ID#(ifapplicable) - t. - -_ t. - 1 -
3926 GLENWOOD DRIVE CHARLOTTE 28208
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG 2L REMARKS
County Parcel Identification No.(PIN) BENTONITE 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): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this forni,I hereby certify that the we/l(s)was(here)constructed in accordance wilh
7.IS this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Iflhis•is a repair,Jill out known well construction information and explain the nature of the of this record has been provider/to the well owner.
repair under#21 remarks section or ail the back of this form.
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: 99.0 (ft.)
For uulliple wells list all depihs iftli ferent(example-3@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),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!f wafer 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 praducin>;: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:
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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