GW1--06722_Well Construction - GW1_20231024

I Print Form 1
WELL CONSTRUCTION RECORD (GW-11 For Internal Use Only:
1.Well Contractor Information:
Scott M. Werley 14.WATER ZONES' . - •
Well Contractor Name FROM TO . DESCRIPTION
3344-A 1.5 ft• 3.5 ft. Gray clay/sand
ft ft I '
NC Well Contractor Certification Number •IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
ECS Southeast, LLP FROM TO DIAMETER THICKNESS 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 well 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
DAgricultural DMunicipal/Public 0 ft. 4 ft. 2 in' 0.010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in:
Dlndustrial/Commercial DResidential Water Supply(shared)
18.GROUT _ 1
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
XINon-Water Supply Well: ,,�� ft. ft.
Monitoring DRecovery '. ,r� L yl ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Rerp llt io /
' 2023 19.SAND/GRAVEL PACK(if applicable)
QIAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Dramag'z, Via' ft. 3.5 it #2 silica sand Pour
DExperimental Technology Subsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) DlOther(explain under#21 Remarks) -FROI1t TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
0 ft. 0.25 ft• tan fine grained sand
4.Date Well(s)Completed:9/27/2023 Well ID#SB-02 0.25 ft 0.5 ft brown fine grained silty sand
5a.Well Location: 0.5 ft' 1.75 ft moistbrown fine grained silty sand
Timothy Fridley N/A 1.75 fL 2.0 ft• saturated gray clay
Facility/Owner Name Facility lD#(if applicable) 2.0 ft• 3.0 ft• saturated gray coarse gr. clayey sand
9905 Statesville Road, Charlotte, 28269 3.0 ft. 3.5 ft. saturated gray clay
Physical Address,City,and Zip ft. ft.
Mecklenburg 02509209 21.REMARKS , .
County Parcel Identification No.(PIN) refusal due to cave-in at 40-inches bgs; no odors or
observations of impacts
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(if well field,one lat/long is sufficient) 22.Certification: �N
35.356269 N -80.842170 W i
Ji(d 9/28/2023
6.Is(are)the well(s):DlPermanent or QlTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or :IN. 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:One(1)
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3.5 (ft.) 24a. For All Wells: Submit this Iform within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below topof casing: 1.5 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.)
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 Sunplv&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 the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources . Revised 2-22-2016