GW1-2023-00802_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
ft. TO ft. DESCRIPTION
A - 4226
NC Well Contractor Certification Number n- -+. 15.OUTER CASING for multi-cased'wells OR LINER if a licable)
` ''•'+ ') FROM TO DIAMETER THICKNESS MATERIAL
GEOLOGIC EXPLORATION Ff;. .=P ` -.
in.
Company Name y y -
�, 16.INNER CASING OR TUBING eothermal closed-too
2.Well Construction Permit#: JAN 1 � N 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.);._ l! ,t 0.0 ft- 97.0 ft- 1.0 in. SCH 40 PVC
3.Well Use(check well use): { 1iv+„`''�� ,r\ 17.SC
fr. in.
Water Supply Well: FR MREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 97.0 ft. 99.0 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) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 94.0 ft' PORTLANDBENTONITE SLURRY
MMonitoring ❑Recovery fr. ft.
Injection Well:
ft. ft.
El Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEA7 ENT METHOD
❑Aquifer Test ❑Stormwater Drainage 96.0 fr• 99.0 ft• 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) FROM TO DESCRIPTION color,hardness,sofurock e, min size,etc.
0.0 ft. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 1 1/21/22 Weu ID# BS-29C 1.0 tr. 22.0 ft. BROWN CLAY
5a.Well Location: 22.0 ft' 71.0 it' BROWN SILT
GLIDDEN COMPANY 71.0 ft' 99.0 ft- GRAY SILTY PWR
Facility/Owner Name Facility ID#(if applicable) ft. ft. I
3926 GLENWOOD DRIVE CHARLOTTE 28208 ft. et•
Physical Address,City,and Zip ft. ft.
MECKLENBURG 21.REMARKS
Comity Parcel Identification No.(PIN) BENTONIfE SEAL-94.0-96.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 15' 01.42" N 800 53' 06.45" W r 11/30/22
6.Is(are)the weII(s): EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the tvell(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known we//construction information and explain the nature of the of this record has been provided to the u,e//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: 99.0 (ft.)
For mulliple wells list all depths ifdijjerent(example-3 t@t 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),
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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
1
13b.Disinfection type: Amount:
Forth GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
i