GW1-2023-00849_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT ^, -Y-..;, 14.WATER ZONES Is i
Well Contractor Name a FROM TO DESCRIPTION
I�Fyn - v`M•�'2
A - 4226 JA N 19 ft. fr. i; I
NC Well Contractor Certification Number 2023
15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION to""iz�'t �r 2"'-" 7 �Ij,l FROM TO DUSTER THICKNESS MATERIAL
rt 5 ft. ft. I I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
Z.W¢II CORStrUCtlOn Permit#: FROM TO DIAMETER THICKNESS M IAL
ATER
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 fr 93.0 fr• 1.0 in, SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
PP y FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 93.0 f`' 95.0 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 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fr 89.0 It' PORTLANDBENTONITE SLURRY
MMonitoring ❑Recovery fr. fr.
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 ❑StormwaterDrainage 92.0 fr 95.0 fr. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,ginin size,etc.
0.0 fr 1.0 It. GRASS/TOPSOIL
4.Date Well(s)Completed: 1 1/03/22 Well ID# BS-36C 1.0 ft, 22.0 ft- BROWN CLAY
Sa.Well Location: 22.0 ft' 67.0 ft' BROWN SILT
GLIDDEN COMPANY 67.0 ft- 95.0 ft. GRAY SILTY PWR
Facility/Ownbr.Name— --" -'Facility ID#(ifapplicable)- ---- 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-89.0-92.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
350 15' 01.34" N 800 53' 06.21" W 11/30/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this•form,/hereby certify that the tvell(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 Standor&and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has beenprovided to the wel/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: 95.0 (ft.)
For multiple wells list all depths iftli ferent(example-3@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
Iju•ater lorel is above casing,use"+"
$ 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: (in.) 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:
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018