GW1-2023-00846_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 I t
FROM TO DESCRIPTION
Well Contractor Name _ _ I
s+ ft. ft. t
A - 4226 �
NC Well Contactor Certification Number 15.OUTER CASING for mulfi-cased;wclls OR LINER ifa licable
GEOLOGIC EXPLORATION JAN 1 2023 FROM TO DIAMETER' THICKNESS MATERIAL
ft. ft. ! in.
Company Name
rls, mot.,,,G 16.INNER CASING ORTUBING(geothermal closed-loop)
2.Well Construction Permit#• '�Wolf
3 a FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 rt• 97.0 rL 1.0 in- SCH 40 PVC
3.Well Use(check well use): ft. tt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE 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.
❑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 ft- 94.0 rt. PORTLANDaENTONITE SLURRY
OMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 96.0 rt. 99.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/mck
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) type, rain size,etc.
0.0 ft• 1.0 rt' GRASS/TOPSOIL
4.Date Well(s)Completed: 1 1/14/22 Well ID# BS-31 C 1.0 ft• 22.0 rr. BROWN CLAY
Sa.Well Location: 22.0 ft' 71.0 ft' BROWN SILT
GLIDDEN COMPANY 71.0 ft 99.0 rt• GRAY SILTY PWR
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
3926 GLENWOOD DRIVE CHARLOTTE 28208 rt. ft.
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG 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:
(ifwell field,one lat/long is sufficient) 22.Certification.-
350 15' 01.42" N 800 53' 06.45" W 11/30/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,1 hereby certify that,the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ITNo 15A NCAC 02C.0100 or 15A 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 921 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 1 GW-i is needed. Indicate TOTAL NUMBER of wells (add'See Ovet'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 multiple wells list all depths ifd�erent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
L�0.0 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
Ifwater level is above casing,use"+" I
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
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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:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018