GW1-2023-00924_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ` �' - f ••.
1.Well Contractor Information: JAN 9
JOHNNY BURR
14.WATER ZONES
FROM TO DESCRIPTION s^'' ^-'11 n
Well Contractor Name ft. ft. (�j�,4 t V►�
A - 3098 'Qz
fr. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi ecased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft, in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable trell construction permits(i.e.U/C,County,State,Variance,etc.) 0.0 ft- 35.0 ft. 2.0 in' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35.0 ft' 45.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) i8.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD R AMOUNT
Non-Water Supply Well: 0.0 ft' 31.0 ft' PORTLANDBENTONITE SLURRY
[EMonitoring ❑Recovery ft. rt.
Injection Well: fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(ifa nlicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Storrnwater Drainage 33.0 ft- 45.0 rt. 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 421 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rocktype, rain siu,etc.)
0.0 fr• 20.0 fr• CONCRETE
4.Date Well(s)Completed: 11/29/22 Well ID# MW-B13-385 20.0 ft• 28.0 ft• TAN SILTY CLAY
5a.Well Location: 28.0 ft• 45.0 ft' TAN PWR
COPES - VULCAN
Facility/Owner Name Facility ID#(if applicable) ft. ft.
601 WEST SUMMIT AVENUE CHARLOTTE 28203 ft. ft.
Physical Address,City,and Zip
MECKLENBURG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL^-31.0-33.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Certification:
350 13' 17.12" N 800 51' 50.23" W V6u"`' 12/28/22
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(here)consvructed in accordance with
7.Is this a repair to an existing well: ❑Yes or I!]No 15A NCAC 02C.0100 or 15A NCAC 02C.0200[fell Construction Stmrdarrlr and that a copy
If this is a repair,fill out known well construction hilbrnnalion and explain the nature of the ofthis record inas been provided to the bell olrtier.
repair under 1121 remarks section or on the back of this fm•nn.
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: 45.0 (ft.)
For multiple wells list all depths ifelierew(example-3�00'onnd 2 a 100') Submit this GW-1 within 30 days or well completion per the following:
18.0 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
If 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: 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018