GW1-2023-00812_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES i.
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4226
_• ��...�,1 nrt y,�� fr. fr.
NC Well Contractor Certification Number - ,`. .,� �, j�9 I5.OUTER CASING for multi-cased wells OR LINER ifa licable
GEOLOGIC EXPLORATION FROM TO DIAMETERI THICKNESS MATERIAL
`t ft. ft. in.Company Name [al 1 L !.
16.1NNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: �7,•--,1-�,^.'•',i.-f,l l�l't FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ' nce,etc. 1.0 "'. . SCH 40 PVC
w�
•u
3.Well Use(check well use): et. ft. in.
Water Supply Well: 17.SCREEN _
FROM 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) fr ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 94.0 ft' PORTIANDBENTONITE SLURRY
IflMonitoring DRecovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
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,soill rock type,ginin size,etc.
0.0 ft. 1.0 It. GRASS/TOPSOIL
4.Date Well(s)Completed: 1 1/04/22 Well ID# BS-38C 1.0 ft• 220 ft. BROWN CLAY
5a.Well Location: 22.0 ft. 71.0 fr' BROWN SILT
GLIDDEN COMPANY 71.0 ft. 99.0 ft- GRAY SILTY PWR
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. f 1
3926 GLENWOOD DRIVE CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG 21.REMARKS
County 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 fat/long is sufficient) 22.Certification:
350 15' 01.41" N 800 53' 06.44" W 11/30/22
6.Is(are)the well(s)• INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing dais form,I hereby terrify fruit the irell(s)was(were)construcled in accordance with
7.Is this a repair to an existing well: ❑Yes or [!]No !SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ifihis 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 tinder 921 remarks section or on the back oflhis 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 1 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 nnulfiple wells list all depths ifdi/ferent(exannple-3 a 00'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),
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,'Raleigh,NC 27699-1617
!f wafer 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:
I
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 6-6-2018
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