GW1-2023-00845_Well Construction - GW1_20230112

I
WELL CONSTRUCTION RECORD GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATERZONES i
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4226 -.. _.,_. ,..,
NC Well Contractor Certification Number '~,.; t pp'� t�
�=ll��,.� ti.i j"q?� 15.OUTER CASING far multi-cased wells OR LINER if a dicable
GEOLOGIC EXPLORATION FROM TO DIAM17ETERI THICKNESS MATERIAL
ft. ft. i in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,&61e;4r riance.etc.'r "" 0.0 ft- 88.0 ft- 1.0 '"' SCH 40 PVC
l JAL
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 88.0 fr. 90.0 f" 1.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fr ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 13.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 It' 85.0 ft' PORTLANDBENTONITE SLURRY
i9Monitoring ❑Recovery R. ft.
Injection Well:
1r. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 87.0 ft. 90.0 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 921 Remarks) FROM TO DESCRIPTION color,hardness,soillrock e, rain sae,etc.
0.0 ft- 1.0 ft- GRASS/TOPSOIL
4.Date Well(s)Completed: 11/18/22 Well ID# BS-30C 1.0 It• 18.0 It. BROWN CLAY
5a.Well Location: 18.0 ft' 66.0 ft. BROWN SILT
GLIDDEN COMPANY 66.0 It. 90.0 It. GRAY SILTY PWR
Facility/Owner Name Facility ID#(if applicable) ft. ft. N
3926 GLENWOOD DRIVE CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip ft. ft.
MECKLENBURG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL...85.0-87.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
350 15' 01.25" N 800 53' 06.30" W �. � 11/30/22
6.Is(are)the well(s)• liflPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the irell(s)was(were)constructed in accordance frith
7.is this a repair to an existing well: ❑Yes or [!9No iSA NCAC 02C.0100 or/5A NCAC 02C.0200 We/1 Cotrsiruction siandardv cord that a copy
IJ'this is a repair,fill out known well construction information and explain the nature of the oJ'this record has been provided to the well owner.
repair under 4121 remarks section or on the back of this fbrrn.
23.Site diagram or additional well details:
S.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: 90.0 (ft.)
For multiple wells list al/depths ifd�ereni(example-3 a 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: (ft.) 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-Loop Geothermal Return Wells:Copy to the
(i.e.anger,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 6-6-20I8