GW1-2023-00798_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT
14.WATER ZONES G:
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I I
A - 4226
NC Well Contractor Certification Number 15.OUTER CASING Tor mufti-cased+•wells OR LINER if a licable
GEOLOGIC EXPLORATION t y FROM TO DIAMETER THICKNESS MATERIAL
fr. ft in.
Company Name
�� (dry 16.INNER CASING OR TUBING t eothermal closed-too
2.Well Construction Permit#: I A N ( S 90/3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 8.0 ft. 4.0 in. SCH 40 PVC
3.Well Use(check well use): try ;:s:+�� ��°= ft. ft. in.
Water Supply Well: 17.SCREEN
' FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 8.0 ft' 18.0 ft' 4.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000GPD FROM TO MATERIAL EM PLACEM ENT M ETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 5.0 ft' PORTLANDBENTONITE SLURRY
❑Monitoring ❑Recovery
Injection Well:
fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 7.0 ft. 18.0 ft. 20-40 FINESILICASAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type, min size,etc.
❑Geothermal(Heating/Cooling Return) L'JOther(explain under 421 Remarks)
0.0 ft. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 1 1/22/22 Well ID# SVE-2 1.0 If- 18.0 ft. BROWN CLAY
Sa.Well Location:
ft. n.
GLIDDEN COMPANY ft. f.
Facility/OwneiName 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) BENTONITE SEAL-5.0-7.0 FEET
***
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ...SOIL VAPOR EXTRACTION
(if well field,one fattlong is sufficient) 22.Certification:
350 15' 00.17" N 800 53' 08.44" W A414- � 11/30/22
6.Is(are)the well(s): 119fiermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing dais•form,I hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or [!9No 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction hijbroation and explain the nature of the ofthis record has been provided to the well owner.
repair Wunder#21 remarks section or on the back of this forun.
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.) Submit this GW-I within 30 days of well completion per the following:
For multiple wells Itst all depths ifd�erent(example-3[r 200'and 2@/00')
24a. For All Wells: Original form'to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
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-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,NCi27699-1611
13b.Disinfection type: Amount:
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018