GW1-2022-07822_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES p' .
Well Contractor Name FROM TO DESCRIPTION
A - 3098 ft. ft t
ft. ft.
NC Well Contractor Certification Number 15.OUTER'CASING for multi-cased wells OR LINER'if a licable
GEOLOGIC EXPLORATION FROM To DIAMETER THICKNESS MATERIAL
tt. ft. in.
Company Name
W M0301215 A6.INNER CASING OR TUBING eothermal closed-loo i
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,variance,etc.) 0.0 f ft- 2.0 '" SCH 40 PVC
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 10.0 ft• 25.0 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
❑lrrl ation ❑Wel Is>100,000 GPD FROM TO MATERIAL EMPLACE
M ENT METHOD B AMOUNT
Non-Water Supply Well: 0.0 ft' 6.0 ft' PORTLANDBENTONITE SLURRY
CEMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test OStormwater Drainage 8.0 ft' 25.0 ft. 20-40 FINE SILICA SAND
OExperimental 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,soil/rock type,grain size,etc
0.0 fr• 2.0 ft- BLACK TOPSOIL
4.Date Well(s)Completed: 06/17/22 Well ID# MW-4 2.0 ft' 5.0 ft. RED CLAY
5a.Well Location: 5.0 . ft. 15.0 ft' BROWN SILTY CLAY
CHARLIE BROWN DRYCLEANER 15.0 ft. 25.0 ft• LIGHT BROWN SILTY CLAY
Facility/Owner Name Facility ID#(if applicable) ft. ft. I;
3701 FREEDOM DRIVE CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip ft. ft.
MECKLENBURG .21.REMARKS,
.
County Parcel Identification No.(PIN) BENTONITE SEAL-6.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 14' 54.13" N 800 53' 51.11" W 06/22/22
6.Is(are)the well(s): 15Permanent or OTemporary Signature of Certified Well Contractor <� Date d_
By signing this form,/hereby certify that the.well(s)was(were)convructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [5No /5A NCAC 02C.0100 or l5A NCAC 02C.0200 14 ell Con t Paprla that a copy
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis firm. 23.Site diagram or additional well details: y
You may use the back of thispage,'to r 11,,,,��.., � PramwI'�Ufa
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Y p ovhtlLilt4ti� ,wllructlon info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovel'in Remarks Box).You may also attach atlldhiona1'pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 25.0 (ft.)
For multiple wells list all depths ifdii ferent(example-3 rd 00'and 1 r@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 6.0 (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 (in) 24b. For Injection Wells: Copy toIDWR,Underground Injection Control(IUC)
AUGER Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.ei.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:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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