GW1-2023-00842_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES I
FROM TO DESCRIPTION
Well Contractor Name _
A - 4226 V';&: �,<�l �.' %.''t: ft. ft.
NC Well Contractor Certification Number (� '] 15.OUTER CASING far multi-cased av,,Hs OR LINER if a licable
GEOLOGIC EXPLORATION JAN 1 2023 FROM TO DIAM ETERi THICKNESS MATERIAL
ft. ft. in.
Company Name llliCee?:av' ii Ci ,::: 1,;,,'
� 16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#:
nt'°E"�'" L'
,. 0G! FROM TO DIAMETER THICKNESS MATERIAL
'•'''
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 58.0 ft. 1.0 in. SCH 40 PVC
3.Well Use(check well use): 0.0 It. 38.0 ft. 1.0 In' SCH 40 PVC
Water Supply WcIL 17.SCREEN
pp y FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 58.0 ft' 60.0 ft. 1.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 38.0 ft. 40.0 ft. 1.0 in. .010 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri atlon ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 35.0 It' 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 57.0 ft. 60.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control 37.0 1` 40.0 ft' 20-40 FINE SILICA SAND
❑Geotlermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM I To DESCRIPTION color,hardness,soiUrock type,ginin size,etc.)
0.0 ft. 1.0 It. GRASS/TOPSOIL
4.Date Well(s)Completed: 11/15/22 Well ID# BS-22-B/A 1.0 It• 22.0 If BROWN CLAY
5a.Well Location: 22.0 tt' 50.0 tt' BROWN SILT
GLIDDEN COMPANY 50.0 It• 60.0 It. 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.
M ECKLEN BU RG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-40.0-57.0 FEET&35.0-37.0 FEET
***NESTED WELLS***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 15' 00.27" N 800 53' 06.04" W 11/30/22
6.Is(are)the well(s): EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By sibmning 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
/f this is a repair•fill out known well construction information and explain the nature ofthe of this record has been provided to the well 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: 60.0/40.0 A)
For multiple wells list all depths ifdri erent(example-3 tci 200'annd 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
If irater level is above casing,rise"+"
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:
13b.Disinfection type: Amount:
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018