GW1-2023-00933_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: f
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION ,_
ft. ft. i TS-^
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-ca,oil, [is OR LINER iEa licabie
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 well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft- 49.0 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 49.0 B- 59.0 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 I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 45.0 ft' PORTLANDBENTONRE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well:
rt. rt.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTt11ETHOD
❑Aquifer Test ❑StormwaterDrainage 47.0 ft- 59.0 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#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
0.0 ft. 20.0 ft- CONCRETE
4.Date Well(S)Completed: 12/09/22 well ID# MW-B13-33I 20•0 ft- 50.0 ft- TAN SILTY CLAY
5a.Well Location: 50.0 ft- 58.0 ft' TAN PWR
COPES - VULCAN 58.0 ft- 59.0 ft- ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft. - --
601 WEST SUMMIT AVENUE CHARLOTTE 28203 ft. ft.
Physical Address,City,and Zip
ft. ft.
MECKLENBURG '21.REMARKS ,
County Parcel Identification No.(PIN) BENTONITE SEAL-45.0-47.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certification:
350 13' 17.12" N 800 51' 50.23" W 12/28/22
6.Is(are)the well(s)' Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this fora;1 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 01C.0200 Well Construction Standards and that a copy
If this is a repair,fill oul known well construction information and explain the nature of the ofilds record has been provided to the well owner.
repair under#21 rentarks section or on the back of this form.
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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 59'0 (ft.)
For multiple trel/s list all depths ifdi•/Jerent(example-3 a 00'and 1 a 100') Submit this GW-1 within 30 days of well completion per the following:
28.0 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
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:
i
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018