GW1-2023-00799_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATERZONES 1 i
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4475
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NC Well Contractor Certification Number -• ^ �'
15.OUTER CASING for multi-cased wells OR LINER"if a licable
GEOLOGIC EXPLORATION ` ;b.�x' r° �� �Ni O� FROM TO DIAMETER THICKNESS MATERIAL
ft. I ft. I in.
Company Name J A IV C� ND
j ^i r 16.INNER CASING:OR TUBING "eothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,.Stq✓ery i!a�iat»1 LTdfi3 1✓'`"6 0.0 ft. 10.0 ft. 2.0 '"' SCH 40 PVC
II1tr.+r rr..r4,�z,e�I J
3.Well Use(check well use): r�- - ft. ft. in.
17.SCREEN. :',
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ff 25.0 ft. 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
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 6.0 fL PORTLANDBENTONUE SLURRY
[NMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL' EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 8.0 ft• 25.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilh•ock type,gnin size,etc.
0.0 ft• 1.0 ft. TOPSOIL
4.Date Well(s)Completed: 1 1/22/22 Wcll ID# MW-4 1.0 ft• 10.0 fl- BROWN CLAY
5a.Well Location: 10.0 ft' 25.0 ft' TAN SILTY CLAY
SUNRISE CLEANERS ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
9013 ALBEMARLE ROAD CHARLOTTE 28227 ft. ft.
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG 21.REMARKS
Comity Parcel Identification No.(PIN) BENTONITE SEAL-6.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lit/long is sufficient) 22.Certification:
3SO 12' 47.15" N 800 41' 25.53" N `G %y%y`- � 12/21/22
6.Is(are)the well(s): OPermanent 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 IENo 15A NCAC 02C.0100 or 15A NCAC 02C.r0200 Well Construction Standards and that a copy
1f 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 021 rentarks section or on the back ofthis 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 Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 25.0 (ft.)
For multiple wells list all depths ifdti ferenr(example-3(a 200'and 2 a 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 17.0 (ft) 24a. For All Wells: Original fomq' to Division of Water Resources (DWR),
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: 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
Permit Program,1611 MSC,Raleigh,'NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018