GW1-2023-00839_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
A - 4226 - J ft. ft.
ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION h' FROM TO DIAMETER THICKNESS MATERIAL
.�A 14 ft.
Company Name
16.INNER CASINGOR TUBING eothermal closed-loop)
' _"';;"
In r�a:�.a�n _ t1r
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
_._. --'-••:3
List all applicable well construction permits(i.e.UIC,County,State,.aribrlce,41c.)= 0.0 rL 58.0 rt. 1.0 t"' SCH 40 PVC
3.Well Use(check well use): 0.0 ft. 38.0 rr• 1.0 in. SCH 40 PVC
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 58.0 r" 60.0 rt. 1.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 38.0 r" 40.0 f" 1.0 in. .010 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irr( ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 35.0 ft' PORTLANDBENTONITE 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 ❑StormwaterDrainage 57.0 ft- 60.0 rr. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control 37.0 ft. 40.0 ft. 20-40 FINE SILICA SAND
❑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,soil/mck type,gnin size,etc.
0.0 f. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 11/18/22 Well ID# BS-19-B/A 1.0 fr• 22.0 rt. BROWN CLAY
5a.Well Location: 22.0 rr. 50.0 ft' BROWN SILT
GLIDDEN COMPANY 50.0 rt• 60.0 rt• GRAY SILTY PWR
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3926 GLENWOOD DRIVE CHARLOTTE 28208 rt. ft.
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG 21.REMARKS
Comity Parcel Identification No.(PIN) BENTONITE SEAL-40.0-57.0 FEET&35.0-37.0 FEET
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***NESTED WELLS
(if well field,one lulling is sufficient) 22.Certification:
35° 15' 00.27" N . 800 53' 06.04" W Am-tt,A,,,,,,`-� 11/30/22
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 will;
7.Is this a repair to an existing well: ❑Yes or 15No 15A NCAC 02C.0100 or I5A 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#21 remarks section or on the back of this forn+.
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: 60.0/40.0 (ft.)
For multiple wells list all depths iJdierent(example-3 ref 200'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),
10.Static water level below top of casing: A) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water 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-Loan 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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,�NC 27699-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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