GW1-2022-08681_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CA RL CARPENTER 14.WATER ZONES
Well Contractor Name FROM TO DESCRn'7'ION
ft. ft.
A - 4475 p A ' ft. fr
NC Well Contractor Certification Number E(_0 Il`A r- I5.OUTER CASING for multi-cased.wells OR LINER if a licable
GEOLOGIC EXPLORATION S 444< FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 1
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: . FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U ounty, rtg� r �etc. 0.0 ft• 8.0 ft 2.0 1° SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREENFROM TO DIAMETER'S SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8.0 1" 18.0 ft' 2.0 1n. .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>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It. 4.0 ft' PORTLAND BENTONITE SLURRY
IEMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.'SAND/GRAVEL,PACK if applicable)-
El Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 6.0 ft- 18.0 ft. 20-40 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) El Other(explain under#21 Remarks) FROM TO I DESCRIPTION color,hardness,sail/mck type rain size,etc.
0.0 ft. 1.0 ft. ASPHALT/GRAVEL
4.Date Well(s)Completed: 05/16/22 Well ID# MW-3 1.0 ft. 5.0 ft. RED CLAY
Sa.Well Location: 5.0 ft' 15.0 ft' RED SILTY CLAY
LONGS CLEANERS 15.0 ft. 18.0 ft. PWR/ROCK
Facility/Owner Name Facility ID#(if applicable) ft. ft. i
918 EAST MOREHEAD STREET CHARLOTTE 28204 f. ft.
Physical Address,City,and Zip ft. ft.
M ECKLE N BU RG 21.REMARKS'
County Parcel Identification No.(PIN) BENTONITE SEAL-4.0-6.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 12' 47.61" N 800 50' 40.10" W 05/26/22
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this farm,I hereby certijy that the ivell(s)was(svere)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards 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 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 construction info
construction,only 1 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: 18.0 (ft)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 12.0 (ft) 24a. For All Wells: Original fonn to Division of Water Resources (DWR),
If wafer 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 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 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-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018