GW1-2023-00859_Well Construction - GW1_20230112

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4226 --- -�:
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased"wells OR LINER if a licablc)
GEOLOGIC EXPLORATION JAN � � ,@ FROM TO DIAMETER THICKNESS MATERIAL
_ C!ltl ft. ft. in.
Company Name
16.INNER CASING OR TUBING eother at closed-loop)
�^+'--'1f� -^ - 1..• FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: .�1,,,
List all applicable well construction permits ri.e.UIC.County;$tare?'Vhkibhl e,etc.) 0.0 ft. 57.0 ft. 1.0 1°' SCH 40 PVC
3.Well Use(check well use): 0.0 ft. 38.0 ft. 1.0 in- SCH 40 PVC
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 157.0 1" 59.0 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) Is.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 fr• 35.0 ft' PORTLANDBENTONITE SLURRY
InMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PAC K ifa nlicahle
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 56.0 ft. 59.0 ft' 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)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,ginin size,etc.
0.0 ft. 1.0 ft• GRASS/TOPSOIL
4.Date Well(s)Completed: 11/01/22 well ID# BS-14-B/A 1.0 ft. 22.0 ft. BROWN CLAY
5a.Well Location: 22.0 ft' 50.0 ft' BROWN SILT
GLIDDEN COMPANY 50.0 ft. 59.0 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) BENTONUE SEAL-40.0-56.0 FEET&35.0-37.0 FEET
***NESTED WELLS***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 15' 00.37" N 800 53' 06.03" W '' 11/30/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
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
If this is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the we/l awner.
repair under 921 remark[section or on the back ofthis fornn.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTION
9.Total well depth below land surface: 59.0/40.0 (ft.)
For multiple wells list all depths ifdoerent(example-3@200'and 2 a 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),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f water 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 producing 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:
Form GW-I North Carolina Department of Envirommental Quality-Division of Water Resources Revised 6-6-2018