GW1-2023-00789_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4226 ft. ft.
NC Well Contractor Certification Number
IS.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EX P LO RATIO FROM TO DIAMETER THIC[4`IESS MATERIAL
" r ft. ft. in.
Company Name ����
JAN IL v 16.INNER CASING ORTUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable we//construction permits ri.e.UIC,County,State,variaq(e, tF.)I•,_ 0.0 ft, 88.0 ft. to in. SCH 40 PVC
3.Well Use(check well use): 1n f ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 88.0 ft' 90.0 ft' 1.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I8.GROUT '
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 85.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a 'licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 87.0 It- 90.0 tc 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) E4.O
TO DESCRIPTION color,hardness,soil/rock e, rain size,elc.)
ft. 1.0 It- GRASS/TOPSOIL
4.Date Well(s)Completed: 10/25/22 Well ID# BS-41 C 24.0 ft- BROWN CLAY
Sa,Well Location:
67.0 ft- BROWN SILT
GLIDDEN COMPANY 67.0 ft. 90.0 ft- GRAY SILTY PWR
Facility/Owner Name Facility ID#(if applicable) ft. ft. -
3926 GLENWOOD DRIVE CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-85.0-87.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 15' 00.73" N 800 53' 07.20" W 11/30/22
6.Is(are)thewell(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,i hereby certify that the well(s)was(here)constructer!in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo IJA 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 ofthis•record has been provided to the well'owner.
repair under 921 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 Ove1'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 90'0
For multiple wells list all depths ifdierent(example-3@200'and 1@100� Submit this GW-1 within 30 days of well completion per the following:
40.0 24a. For All Wells: Original form,to Division of Water Resources (DWR),
f Static water level below top of casing: (fo Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If crater level is abate casing,use"+"
11.Borehole diameter: 8.0 (in,) 24b. For Injection Wells: Copy to DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 276I99-1636
12.Well construction method: SONIC
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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
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13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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