GW1--06721_Well Construction - GW1_20231024

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: •
Scott M.Werley 14.WATER ZONES •
Well Contractor Name FROM TO 'DESCRIITION
1.0 ft- 5.0 ft-
3344-A .
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
ECS Southeast, LLP FROM TO DIAMETER, THICKNESS 1 MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
WM0301315&SIP#70003159 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
List all applicable iron construction permits(i.e.UIC.County,State,Variance,etc.) ft. ft. • in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER'. SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public o ft. 5 ft. 2 in: 0.010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in',
Industrial/Conmmercial OResidential Water Supply(shared) 18.GROUT '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: • ft. ft.
x Monitoring I®IRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stonnwater Drainage o ft. 5 ft. #2 silica sand Pour
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Retum) nOther(explain under#21 Remarks)
0 ft• to ft. brown coarse grained sand
4.Date Well(s)Completed:9/27/2023 Well ID#Si3-01 1 o ft. 2 o f[.
p blueish gray silty clay;wet at 1.0 ft
5a.Well Location: 2.0 ft. q p ft. blueish gray soarse grained clayey sand
Timothy Fridley N/A 4.0 ft 5.0 ft• blueish gray fine grained sa iy clay r
Facility/Owner Name Facility ID#(if applicable) R. ft. „ : it ',' .�'
9905 Statesville Road, Charlotte, 28269 ft. ft. ��; �.•Y
Physical Address,City,and Zip ft. ft. 79:-/:-.1,2-1°!---3-
!n,21.REMARKS ' `^''C.c Mecklenburg 02509209 O,_"-sn ,_' .
County Parcel Identification No.(PIN) ' "~�fi"A
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certif cation:
35.356269 N -80.842170 C\
9.28.2023
6.Is(are)the well(s)0 Permanent or Temporary Signature of Certified We C [ cto Dater
By signing this farm,i hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: D Yes or 0 No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 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 back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:'"et')
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5'0 (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list al/depths ifdiffiyent(example-3@200'200'and 2 a l00') construction to the following:
10.Static water level below top of casing: 1'0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3.25 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
hand auger above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
t •
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) - Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit' one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to I
the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016