GW1-2023-00813_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
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A - 4226 ft. ft._ _ _ I
ft. fr. l
NC Well Contractor Certification Number Z j` �� �; j" 15.OUTER CASING for multi-case8 wells OR LINER if a I licable
k�e..r...-ten'
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. 1 � in.
Company Name 91 '
16.INNER CASING OR TUBING 'eoihermal closed-loop)
2.Well Construction Permit#: 1._- s: �❑ ;*� ^. ia1 i Ir.' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,%l aea cr ,-to) V 0.0 ft. 97.0 ft. 1.0 1 t"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
All.SCREEN
Water Supply Well:PPy FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 97 01" 99.0 1" 1.0 1.: .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in1
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fr. 94.0 ft' PORTLANDaENTONITE SLURRY
MMonitoring ❑Recovery 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
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑OtlTer(explain under 421 Remarks) FROM TO DESCRIPTION color,ha,dness,soil/rocke,grain size,etc.
0.0 ft• 1.0 ft• GRASS/TOPSOIL
4.Date Well(s)Completed: 10/26/22 Well ID# BS-40C 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)
3926 GLENWOOD DRIVE CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG 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:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 15' 01.37" N 800 53' 06.32" W 11/30/22
6.Is(are)the well(s): 1191lermanent 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 MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
ifthis it a repair,fill out known well construction information and explain the nature of the of this record has been provided to the ivell owner.
repair under#21 remarks section or on the back of this 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.)
Eor multiple hells list all depths iftli ferent(example-3 a 00'otd 2 a 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),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJ'woler 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:
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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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