GW1-2023-00808_Well Construction - GW1_20230112

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES % I
Well Contractor Name FROM TO DESCRIPTION
A - 2581 -r„ , _ ;- rt. ft. I
!,
NC Well Contractor Certification Number 15.OUTER CASING-for multi-casedavells OR LINER if a licable
GEOLOGIC EXPLORATION JAN 1 2 202� FROM TO DIAMETER' THICKNESS bATERIAL
ft. ft. in.
Company Name
:I+ . t 16ANNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: t^)s,I};'q. •;, " FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C County,State,Variance,etc.) 0.0 ft. 20.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 fL 40.0 ft' 2.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EM PLACEMENT M ETHOD d AMOUNT
Non-Water Supply Well: 0.0 ft. 5.0 It" PORTLANDaENTONITE SLURRY
❑Monitoring ❑Recovery rt. fr.
Injection Well:
rr. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19,SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stornwater Drainage 17.0 ft• 40.0 rt• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control fr. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTIONcolor,hardness,soi0rock rain sin,etc.)
❑Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) e,
0.0 It. 1.0 ft• ASPHALT/CONCRETE/GRAVEL
4.Date Well(s)Completed: 10/20/22 Well ID# PZ-2 1.0 It. 9.0 tt• RED SILTY SANDY CLAY
5a.Well Location: 9.0 ft• 21.0 1" RED SILT
EASTWAY SHOPPING CENTER 21.0 1" 40.0 It. TAN SILTY SAND
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1314 CENTRAL AVENUE CHARLOTTE 28205
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 5.0-17.0 FEET
***PIEZOMETER***
ib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 13' 08.51" N 800 48' 56.56" W - 10/24/22
6.is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this firm,]hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,Jill out known well construction information and explain the nature of the ofthi.s record has been provided to the we//owner.
repair under 021 remarks section or on the back of this fbnn.
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: 40.0 (ft.)
I or multiple wells list all depths ifdtfJereni(example-3(a 200'and 2Q100') Submit this GW-1 within 30 days of well completion per the following:
18.0 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
lftrater level is above casing,use•'+"
11.Borehole diameter: 6.0 (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 27699-1 6 1 1
13a.Yield(gpni) Method of test:
13b.Disinfection type: Amount:
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018