GW1-2023-00811_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
KENNY SARGENT 14.WATERZONES
Well Contractor Name ^-� FROM TO DESCRIPTION
A - 4226 �-^�
_ 3 �. '.1 ft. ft.
NC Well Contractor Certification Number {� 15.OUTER CASING for multi-cased dells OR LINER if a licable
GEOLOGIC EXPLORATION IA� v �U�� FROM TO DIAMETER THICKNESS MATERIAL
•l ft. ft. in.
Company Name �.,• t j;j',;
16.INNER CASING OR TUBING eothermal closed-loop)
1 ,u��"'d' ' •->,(�" FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: It r.��;i";;.,-.�-
List all applicable Weil construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 97.0 ft. 1.0 1°' SCH 40 PVC
3.Well Use(check well use): ft. ft. ; in.
Water Supply Well: 17.SCREEN i;
FROM TO I DIAMETER. SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 97.0 ft. 99.0 ft. 1.0 in•1 .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in•1
❑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' PORTLAND,BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Relmediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 96.0 ft. 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 421 Remarks) FROM To DESCRIPTION(color,hardness,soillrock type,gnin sire,etc.)
0.0 ft. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 10/27/22 Well ID# BS-37C 1.0 ft- 22.0 ft- BROWN CLAY
Sa.Well Location:
22.0 ft' 71.0 ft' BROWN SILT
GLIDDEN COMPANY 71.0 ft. 99.0 ft. GRAY SILTY PWR
Facility/Owner Name - Facility ID#(if applicable) ft. ft.
3926 GLENWOOD DRIVE CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip ft. ft.
MECKLENBURG 21.REMARKS
Comity Parcel Identification No.(PIN) BENTONITE 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' 01.40" N 800 53' 06.34" W AA� ,,, ,'- 11/30/22.
6.Is(are)the well(s): 119liermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(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 well construction information and explain the nature of the ofthis record has been provided to the well-owner.
repair under 921 remarks section or on the back ofthis 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-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: 99.0 (ft.)
For hnultiple wells list all depths ijdi/ferent(example-3 n 00'and 2 a@100') Submit this GW-1 within 30 days of well completion per the following:
40.0 24a. For All Wells: Original forth to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifwalcr 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:
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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