_Well Construction - GW1_20230310 (6)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name - - - •'" FROM TO DESCRIPTION
ft-
A - 3098 ft. ft.
NC Well Contractor Certification Number [� t023
M AEA � 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name -
v'•°' '' 16.INNER CASING OR TUBING eother at closed-loop)
2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,Stare,Variance,etc.) 0.0 ft- 35.0 ft. 2.0 in. SC H 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35.0 fL 45.0 It- 2.0 in- .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
oirrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 31.0 rt' PORTLANDBENTON17E SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge MGroundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 33.0 ft- 45.0 fL 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,sodhvsk type,grain size,etc.(
0.0 1" 15.0 fL CONCRETE/BRICK BACKFILL
4.Date Wells)Completed: 02/09/23 Well ID# IW-13-23B 15.0 ft- 28.0 ft. RED/ORANGE CLAY
Sa.Well Location:
28.0 ft. 45.0 fL TAN SILTY CLAY
COPES - VULCAN "' f''
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
601 WEST SUMMIT AVENUE CHARLOTTE 28203 ft. fL
Physical Address,City,and Zip ft. ft.
MECKLENBURG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL_- 31.0-33.0 FEET
Sb.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 800 51' 50.23" W �"' 02/21/23
6.Is(sre)the well(s): (EPermanent or ❑Temporary Signature of Certified 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 MNo /SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
df this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 111l remarks section or on the back ofthts 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 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.)
Far multiple wells list all depths ifdijjerent(example-3@200'and 2@1001 Submit this GW-1 within 30 days of well completion per the following:
30.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 00 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lf'water level is above easing,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 O n-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department o the county w ere installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100 000 GPD:Copy to DWR,CCPCUA
Permit Program,161 I MSC,Ra eig ,NC 27699-1611
13s.Yield(gpm) Method of test:
13b.Disinfection type: amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018