GW1-2023-00810_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES I
Well Contractor Name _r l- ^^•" FROM TO IDESCRIPTION
A - 2581 � a
ft. ft.
NC Well Contractor Certification Number p AI
F 1I`7 2, 15.OUTER CASING far multi-cased avells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. in.
Company Name lni+ '1 t 1! ft.
16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 fr. 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 I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 20.0 rt' 40.0 n- 2.0 tn' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 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 ft. PORTLANDBENTONITE SLURRY
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Storinwater Drainage 17.0 rt. 40.0 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,sail rock e, min size,etc.)
❑Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0.0 rt• 1.0 rr• ASPHALT/CONCRETE/GRAVEL
4.Date Well(s)Completed: 10/20/22 Well ID# PZ-4 1.0 et• 9.0 ft. RED SILTY SANDY CLAY
5a.Well Location: 9.0 rr• 21.0 ft' RED SILT
EASTWAY SHOPPING CENTER 21.0 ft. 40.0 ft. TAN SILTY SAND
Facility/Owner Name Facility ID9(if applicable) 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
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***PIEZO M ETER***
(if well field,one]at/long is sufficient) 22.Certification:
350 13' 08.51" N 800 48' 56.56" W !�:f:snz;_ 0'`r- 10/24/22
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 ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If.this is a repair,fil/our known well construction information and explain the nature oftle of7his record has been provided to the well owner.
repair under 421 remarks section a•on the back of this•form.
23.Site diagram or additional well details:
S.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-I 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.)
For multiple wells list al/depths ifdiJjerent(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: 18.0 (rt) 24a. For All Wells: Original form to Division of Water Resources (DWR),
1/11'a1L'Y level IS above casing,use•'+•• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IL 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 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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