GW1-2023-00847_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: f
1.Well Contractor Information:
KENNY SARGENT 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4226 _ ft• ft•
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased`weIts OR LINER if a licable
W 1`
FROM TO DIAMETER! THICKNESS MATERIAL
GEOLOGIC EXPLORATION
I n t�I ft. ft. 'in.
Company Name J H N 1 S I- 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.UIC,Couny{'idte;`Vdt;ivae,•erc,J- ." O.0 ft- 97.0 ft- 1.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
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.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METH OD&ANIOUNT
Non-Water Supply Well: 0.0 ft- 94.0 ft' PORTLANDBENTONITE SLURRY
(EMonitoring ❑Recovery ft. ft.
Injection Well:
ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stonnwater Drainage 96.0 ft- 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)
OGeotlTermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.
0.0 ft. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 11/O7/22 Well ID# BS-34C 1.0 ft- 22.0 ft. BROWN CLAY
5a.Well Location: 22.0 ft• 71.0 1t' BROWN SILT
GLIDDEN COMPANY 71.0 It- 99.0 fc, GRAY SILTY PWR
-Facility/Owner Name- - Facility ID'#(if applicable) "--- ft. ft. -
3926 GLENWOOD DRIVE CHARLOTTE 28208
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:
(ifsvell 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): i5Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was 6vere)constructed in accordance kith
7.Is this a repair to an existing well: ❑Yes or MNo 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 of this record has been provided to the trell 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-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
For multiple wells list all depths ifdierent(example-3 r@1t 200'and 2 rJ100) Submit this GW-1 within 30 days of well completion per the following:
4.0.0 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
If crater 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'Loon 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 producingiover 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,�NC 27699-1611
13a.Yield(gpm) Method of test:
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13b.Disinfection type: Amount:
Font OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018