GW1-2023-00809_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 2581 ft. ft.
NC Well Contactor Certification Number = nF _.15.OUTER CASING for multi-cased 1Vells OR LINER if a licable
GEOLOGIC EXPLORATION:; .,.,v}, II+�' FROM TO DIAMETER' THICKNESS MATERIAL
ft. ft. in.
Company Name ZO��
JAN � � l.1 16:INNER CASING OR TUiIING eotltermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Saie.V 1 ia�tce,.�etv:,��;;;'))!i':,': O.O ft' 20.0 ft' 2.0 in' SCH 40 PVC
ni<;1a _ in.
3.Well Use(check well use): ,jt,'i =%� R. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 ft' 40.0 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
❑Irrl ation ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 5.0 f[. PORTLANDBENTONITE SLURRY
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
`19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 17.0 ft• 40.0 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) ItOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
0.0 ft• 1.0 fr• ASPHALT/CONCRETE/GRAVEL
4.Date Well(s)Completed: 10/20/22 Well ID# PZ-3 1.0 fc• 9.0 ft• RED SILTY SANDY CLAY
5a.Well Location: 9.0 tr' 21.0 ff RED SILT
EASTWAY SHOPPING CENTER 21.0 fr• 40.0 fr• TAN SILTY SAND
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1314 CENTRAL AVENUE CHARLOTTE 28205 ft. ft.
Physical Address,City,and Zip ft. ft.
MECKLENBURG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL 5.0 17.0 FEET
***PIEZOMETER***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
350 13' 08.51" N 800 48' 56.56" W f2f Snz�,. fir-- 10/24/22
6.ls(are)the well(s): iNPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify ihai the IreH(s)was(were)consiructed 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
1f this is a repair,fill oar kiiou,ti well constructimr inforniatimr and explain the nature of Jie of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofihis 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: 40•0
For multiple wells list all depihs(/'different(exaniple-3@200'and 2 a 100') 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
1fwater level is alcove casing,use"+" i
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
Penn it Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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