GW1-2022-08683_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4475 $� fr. fr.
NC Well Contractor Certification Number CU 8 15.OUTER CASING formulN-cased"wells OR LINER ifa livable
.GEOLOGIC EXPLORATION A�A" 6) n �022 FROM TO DIAMETER THICKNESS MATERIAL
ElT y7 ft. ft. in.
Company Name
a1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: Pfif FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1.e.UIC,County,State ➢i ,etc.) 0.0 ft. 8.0 ft. 2.0 °n' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.,SCREENFROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8.0 ft. 18.0 It' 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
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 4.0 ft. PORTLANDBENTONnE SLURRY
INMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a livable-
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El 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) ❑Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soiltrock type rain size,etc.
0.0 ft. 1.0 rt• ASPHALT/GRAVEL
4.Date Wells)Completed: 05/17/22 Well ID# MW-2 1.0 ft. 5.0 ft- RED CLAY
Sa.Well Location: 5.0 It. 15.0 ft' RED SILTY CLAY
LONGS CLEANERS 15.0 ft• 18.0 % PWR/ROCK
ft.
Facility/Owner Name Facility ID#(if applicable) ft. '
918 EAST MOREHEAD STREET CHARLOTTE 28204 ft. ft.
Physical Address,City,and Zip ft. ft.
M EC KLEN B U 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" � � � 05/26/22
6.Is(are)the well(s): ITPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)ivas(were)constructed in accordance ivith
7.Is this a repair to an existing well: ❑Yes or ONo ISA NCAC 02C.0100 or ISA 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 ofthe ofthis record has been provided to the ivell 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-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: 18.0 (ft.)
For multiple ivells 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: 16.0 (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 to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supp1Y 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
Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018