GW1-2023-00844_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES E
Well Contractor Name FROM ft. TO DESCRIPTION
`
A - 4226 ft.
4� , q',.�T'}• ft. ft.
NC Well Contractor Certification Number "� R a 4
=" 15.OUTER CASING for muH�-cased:wetls OR LINER if a dicablc
GEOLOGIC EXPLORATION AA'' FROM TO DIAMETER, THICICNFSS MATERIAL
IQ'V ? 7q ft. ft. ! in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop
2.Well Construction Permit#:
{f li�•i:ii•.'.�-1 a r: .ti::'� l.lr,if FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County;Slatd,drariaiicc,etc.) 0.0 ff 97.0 ft- 1.0 i"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM
SCREEN
FROM TO DIAMETER SLOTSIZE 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) ft. ft. in.
❑lndustriaUCominercial ❑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' PORTLANDBENTONITE SLURRY
[5Monitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 96.0 ft- 99.6 ft- 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soithock type,ginin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft 1.0 ft GRASS/TOPSOIL
4.Date Well(s)Completed: 1 1/1 0/22 Well ID# BS-32C 1.0 ft• 22.0 fr• BROWN CLAY
5a.Well Location: 22.0 ft' 71.0 ft' BROWN SILT
GLIDDEN COMPANY 71.0 ft- 99.0 It- GRAY SILTY PWR
Facility/Owner Name_ Facili ID#(if applicable) - ft. ft. - -
3926 GLENWOOD DRIVE CHARLOTTE 28208
Physical Address,City,and Zip ft. ft.
MECKLENBURG 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)at/long is sufficient) 22.Certification:
350 15' 01.42" N 800 53' 06.45" W r 11/30/22
6.Is(are)the well(s): (51'ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this•form,/hereby certify that the well(s)tras(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IJNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constnictior Standards and that a copy
/J•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 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-1 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 tindtiple wells list a//depths ifdii ferent(example-3@200'and 2 a 100') Submit this CW-1 within 30 days of well completion per the following:
40.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
j'i Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
IJ'u•ater 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 27699-1 6 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: 1
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources + Revised 6-6-2018
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