GW1-2023-00795_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES l
Well Contractor Name FROM TO DESCRIPTIONft. ft. 1
A - 4226 ft. ft.
NC Well Contractor Certification Number _ 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION .' `•„ '.- +J. j FROM TO DIAMETER : THICKNESS MATERIAL
Company Name
(�
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit# BAN A v 20Z3 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable bell construction permits(i.e.UIC,Canny,State,Variance,etc.) 0.0 ft. 58.0 ft. 1.0 '" SCH 40 PVC
3.Well Use check well use): 'iC') :'Ci ^:�J L;i :i 0.0 ft. 38.0 ft• 1.0 in.
( ) SCH 40 PVC
Water Supply Well: .-SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 58.0 rt' 60.0 fL 1.0 in. O10 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 38.0 ft' 40.0 ft. 1.0 in. .010 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EM PLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 35.0 ft. PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 57.0 tt• 60.0 tt• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control 37.0 ft. 40.0 ft. 20-40 'FINE SILICA SAND
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soillrock e, min size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 rt• 1.0 rt• GRASSfiOPSOIL
4.Date Well(s)Completed: 11/16/22 Well ID# BS-4-B/A 1.0 ft. 22 0 tt• BROWN CLAY
5a.Well Location: 22.0 rt' 50.0 ft' BROWN SILT
GLIDDEN COMPANY 50.0 ft- 60.0 ft. GRAY SILTY PWR
- _ Facility%Owner Name - - Facility ID#(ifapplicable) - 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) BENTONITE SEAL-40.0-57.0 FEET&35.0-37.0 FEET
Sb.Latitude and longitude indegrees/minutes/seconds or decimal degrees:
***NESTED WELLS***
(ifwell field,one lat/long is sufficient) 22.Certification:
350 15' 00.27" N 800 53' 06.04" W #Ww'd .A,,,,,,,-@- 11/30/22
6.Is(are)the well(s)• [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this•form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo i5A NCAC 02C.0100 or 15A NC4C 02C.0200 Well Construction Standards and that a copy
/fthis•is a repair,fill oat known well construction information and explain the nature ofdte ofthis record has been provided to the well onder.
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 i 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: 60.0/40.0 (ft.)
For nmhiple wells list all depths ifdierent(example-3@200'and 2@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),
Ifwater level is above caring,we"+"
f Static water level below top of casing: (ft.) 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: SONIC
24c.For Water Supply and Open-Loon 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 27699-161 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: I
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018