GW1-2023-00850_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
A - 4226 :; - - , ,
NC Well Contractor Certification Number
-' 15.OUTER CASING for molt*-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION JAN 1 7 FROM ft. TO ft. DIAMETER in THICKNESS M1tATERIAL
Company Name
if Fn :,;^l -ji`, y^' t 16.INNER CASING OR TUBING eothermal closed-loo I
2.Well Construction Permit#: naa .a l FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perinits(i.e.UIC,County,Slate; 0.0 ft. 58.0 ft. 1.0 1n. SCH 40 PVC
3.Well Use(check well use): 0.0 ft. 38.0 ft- 1.0 in. SCH 40 PVC
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 58.0 1" 60.0 ft' 1.0 in. .010 SCH 40 PVC
❑GeotlTermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 38.0 ft' 40.0 ft. 1.0 in. .010 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrrl ation ❑WeIIs>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 35.0 ft' PORTLANDBENTONITE SLURRY
MMonitoring ❑Recovery
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
❑AgLliferTest ❑StonmwaterDrainage 57.0 ft- 60.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control 37.0 ft. 40.0 ft. 20-40 FINE SILICA SAND
[]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 ft. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 11/10/22 Well ID# BS-S-B/A 1.0 ft• 22.0 ft• BROWN CLAY
Sa.Well Location: 22.0 ft. 50.0 ft' BROWN SILT
GLIDDEN COMPANY 50.0 ft. 60.0 ft. GRAY SILTY PWR
Facility/Owner Name Facility 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-40.0-57.0 FEET&35.0-37.0 FEET
***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***NESTED WELLS
(if well field,one]at/long is sufficient) 22.Certification:
3SO 15' 00.27" N 800 53' 06.04" W If „�, d, A,,- 11/30/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(here)constructed in accordance with
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 ilia!a copy
If flits is a repair,fill out known well construction information and explain the nature of the of flits record has been provided to life 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ove?in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 60.0/40.0
For inulliple wells list all depths ifdi/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),
f Static water water level is abovem casing.
sing,arse"+below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
!f a "
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 departmint 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:
r '
Font GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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