GW1-2023-00801_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 i s
Well Contractor Name FROM TO DESCRIPTION
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A - 4226
NC Well Contractor Certification Number ! ^ ^ 15.OUTER CASING for multi-cased'wells OR LINER if a licable
GEOLOGIC EXPLORATION Px '� 4C`'i1c ins '` FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name J A I V i n '1
2l'7 J 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pertnits(i.eat((^,;; Dlyiiyn.�taik;;6'arran{j,-�c.,�r' 0.0 ft- 95.0 ft- 1.0 in. SCH 40 PVC
ft.
3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 95.0 ft' 97.0 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)
18i GROUT
❑Irri ation 0Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 92.0 ft' PORTLAND BENTONITE SLURRY
INMonitoring ❑Recovery ft. ft.
Injection Well:
fr. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 94.0 ft. 97.0 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 921 Remarks) FROM TO DESCRIPTION color,hardness,soit/rock e, rain size,etc.
0.0 ft. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 1 1/22/22 Well ID# BS-28C 1.0 ft. 20.0 ft. BROWN CLAY
5a.Well Location:
20.0 fr. 58.0 ft. BROWN SILT
GLIDDEN COMPANY 58.0 ft. 97.0 ft. GRAY SILTY PWR
Facility/Owner Name Facility ID#(if applicable)
3926 GLENWOOD DRIVE CHARLOTTE 28208 rt. rt•
Physical Address,City,and Zip
MECKLENBURG 21.REMARKS '
County Parcel Identification No.(PIN) BENTONITE SEAL-92.0-94.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 15' 01.36" N 800 53' 06.33" W 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 ivell(s)ivas(were)constructed in accordance n'uh
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a copy
if this is a repair,ftl/out known ire/l construction information and explain the nature of the of this record has been provided to the ive/l 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 i 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: 97.0 (ft.)
For multiple wells list al/depths ifdii ferent(example-3 r�200'and 2 a 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),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Iftvater 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-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 27699-1611
13a.Yield(gpm) Method of test:
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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