_Well Construction - GW1_20230310 (9)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft ft
A - 3098
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name "t
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. County,.4tate,'Variance,etc.) 0.0 ft. 25.0 ft 2.0 1O' 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 25.0 B' 35.0 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
❑Irrigation ❑Wells>100000 GPD FROM I TO MATERI U. EMPLACENi ENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 21.0 �• PORTLANDBENTONRE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge 25Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 23.0 It- 35.0 ft• 20-40 J 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 I TO DESCRIPTION color,hardness,soiUmck type,Krain size,etc.
0.0 ft• 14.0 1" CONCRETE/BRICK BACKFILL
4.Date Well(s)Completed: 02/10/23 Well ID# IW-13-23A 14.0 ft. 23.0 fL RED/ORANGE CLAY
5a.Well Location: 23.0 It' 35.0 ft. TAN SILTY CLAY
COPES - VULCAN it• ft.
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-21.0-23.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 13' 17.12" N 800 51' 50.23" W �'r'L'� 02/21/23
6.Is(are)the well(s): IMPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,/hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under 921 remarks 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 bark of this page to provide additional well construction info
construction,only I GW-I 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: 35.0 (ft.)
For multiple wells list all depths iJ'difjereni(example-3@200'and 2@I00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 30•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 (ily) 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 roducin over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 61 1
13b.Disinfection hype: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018