GW1-2023-00852_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.3VATERZONES V
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 4226 : .';�, -, ;y fr. Ir•
NC Well Contractor Certification Number r .c3y
15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION NI FROM TO DIAMETER THICKNESS MATERIAL
J�'` 1 � �Q�� ft. ft. in.
Company Name
IDS _�.; •, �_• 'i„ IG.INNER CASING OR TUBING eothermal closed-loo
•l� ' °• =' •:..,� L,II',�f FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: :+
List all applicable hell construction permits(i.e.UIC,County;State;VaNdh&etc.) 0.0 ft- 58.0 ft- 1.0 'n' SCH 40 PVC
3.Well Use(check well use): 0.0 ft. 38.0 ft- 1.0 in- SCH 40 PVC
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 58.0 ft. 60.0 ft. 1.0 in- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 38.0 ft. 40.0 ft- 1.0 in. .010 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 35.0 ft- PORTLANDBENTONITE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well:
fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 57.0 ft- 60.0 fG 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control 37.0 ft- 40.0 ft• 20-40 FINE SILICA SAND
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiUrock e, ruin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks)
0.0 ft. 10 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 11/15/22 Well ID# BS-7-B/A 1.0 fr• 22.0 ft• BROWN CLAY
5a.Well Location: 22.0 ft• 50.0 Ir' 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 ft. ft.
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-40.0-57.0 FEET&35.0-37.0 FEET
***NESTED WELLS***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 15' 00.27" N 800 53' 06.04" W 11/30/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing(his form,I hereby certijy that the wells)was(were)constructed in accordance with
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,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this fora.
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 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 all depths ifdiJJerent(example-3 rr 200'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 40.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Iftrater level is above casing,use"+"If 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: 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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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