GW1-2022-07824_Well Construction - GW1_20220822

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I
1.Well Contractor Information: k
JOHNNY BURR 14.WATERZONES i .a
Well Contractor Name FROM TO I DESCRIPTION
rt. � '
A - 3098 rt.
ft. ft. I I '
NC Well Contractor Certification Number
is.OUTER CASING for mulN;casedivclls OR LINER if a i licable ,
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS
FSS MATERIAL
ft. ft. in.
Company Name
W M 0301215 '16JNNER CASING OR TUBING 'eothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 5.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
❑Agricultural ❑Municipal/Public
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
S.0 rt• 20.0 fL 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
❑Irri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0•0 ft' 3.0 ft' PORTLAND,BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL.PACK if a `licablc -
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL, rMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 4.0 tt• 20.0 rt• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20 DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soi0rock e, rain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 It. 2.0 ft- BLACK TOPSOIL
4.Date Well(s)Completed: 06/17/22 Well ID# MW-3 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)
3701 FREEDOM DRIVE CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip ft. ft.
MECKLENBURG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-3.0-4.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IatAong is sufficient) 22.Certification:
350 14' 54.22" N 800 53' 51.33" N �j w
G.Is(are)the well(s): OPermanent or ❑Temporary
Signature ofCertified Well Contractor w%� .,.^ �5 +4.'Dtate^
By signing this form,1 hereby eerlify that the well(.' r (uwye)6y', l in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0/00 or ISA NCAC 02C.0200 4'��mia;uoflo�rdr and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the Nell owner.
repair under#21 remarks section or on the back of this form. rfl4"-,1 P rta`z,�a ltq Unit
8#€m 23.Site diagram or additional welll
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page;to provide I 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: 20.0 (ft.)
For multiple wells list all depths rfdifferent(example-3@200'and 2 t@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),
1J•ivaier level is above casing,use"+^ Information Processing Unit,1617 M I SC,Raleigh,NC 27699-1617
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 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 producinl?over 100,000 GP)
: Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh;'NC 27699-161 I
13b.Disinfection type: Amount:
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018