GW1-2023-00939_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ,1�r:-,
1.Well Contractor Information: � =V E j
JOHNNY BURR 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
ft. ft.
A - 3098
ft. ft. CLa/�. Ot
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a tlicable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-fool))
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) 0,0 ff• 33.0 fL 2.0 +.nSCH 40 PVC
3.Well Use(check well use):
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 33.0 ff• 43.0 fL 2.0 in- .010 SCH 40 PVC
❑Geothermal(Heating/Coohng Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EM PLACEMENT M ETHOD&AMOUNT
Non-Water Supply Well: 0•0 ft. 29.0 ft. PORTLANDBENTONiTE SLURRY
InMonitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEAIENTMETHOD
El Aquifer Test ❑Stormwater Drainage 31.0 ft- 430 If- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. It.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑OtlTer(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, min size,etc.
0.0 ft 23.0 ff• CONCRETE
4.Date Well(s)Completed: 12/16/22 Well ID# MW-613-355 23.0 rf• 42.0 fL TAN SILTY CLAY
Sa.Well Location:
ft. ft.
_ ----COPES - VULC_A_N ft. ft.
Facility/Owner Name Facility IDl1(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)
BENTONIfE SEAL-29.0-31.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 13' 17.12" N 80° 51' S0.23" W ���
12/28/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the irell(s)was(were)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
Ifihis is a repair,Jill one known well construction information and explain the nature ofthe ofthis record has been provided to the irell oumer.
repair under 921 remarks section or on the back of this 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 Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 43'0 (ft.)
Tor multiple wells list all depths ifdii ferent(example-3 a 200'and 2@l00') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 28.0 (ft) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If,rater 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:
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018