GW1-2023-00923_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORD GW-1� ) For Internal Use Only:
1.Well Contractor Information: � ' � P) f,..,
rJ
JOHNNY BURR 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098 ft. ft. ti;�jr}3 Un
NC Well Contractor Certification Number ' '"
15.OUTER CASING for multi-cased wells OR LINER if a lica e "
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#• FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable bell construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 fL 55.0 fr' 2.0 " SCH 40 PVC
3.Well Use(check well use): ft. I in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 55.0 ft. 65.0 ft' 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 51.0 ft- PORTLANDBENTONRE SLURRY
INMonitoring ❑Recovery tr. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDlGRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTDIETHOD
El Aquifer Test ❑StormwaterDrainage 53.0 ft 65.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 fr 20.0 ft CONCRETE
4.Date Well(s)Completed: 12/02/22 Well ID# MW-B 13-38I 20.0 ft- 25.0 ft. RED CLAY
5a.Well Location: 25.0 ft. 40.0 ft' TAN SILTY CLAY
COPES - VULCAN 40.0 fr 64.0 ft. TAN PWR
Facility/Owner Name Fiicility 1D#(ifapplicable) 64.0 ft 65.0 fr• ROCK
601 WEST SUMMIT AVENUE CHARLOTTE 28203
Physical Address,City,and Zip ft. ft.
M EC KLEN BU RG 2L REMARKS
County Parcel identification No.(PIN)
BENTONITE SEAL-51.0-53.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3So 13' 17.12" N 800 51' 50.23" W �91-11 12/28/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature ofCertitied Well Contractor Date
By signing this form,I hereby certify that the well(s)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 wel/construction information and explain the nature of the of this record has been provided to the well ou ner.
repair under 1121 remarks section or on the back ofthis firin.
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: 65.0 (ft.)
For inuhiple wells list all depths ifdii ferent(exannple-3 n 00'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of easing: 32.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information 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: 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 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 GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
I