GW1-2023-00851_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 4226
ft. ft.
NC Well Contractor Certification Number A5.OUTER CASING formolt-cased-wells) e ER a
GEOLOGIC EXPLORATION JAN 1 FROM . r0_W=nP!'iS_MATERIAL
2 2023 ft. DIAMETER
in.
Company Name '3 1 1 1
I -,:I,EC l e* J Ir..1 -­16.INNER CASING OR TUBING(gechhermal closed-lbop)'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ive//construction permits(t.e.UIC,County,Stale,Variance,etc.) 0.0 f- 58.0 r- 1.0 in. SCH 40 PVC
3.Well Use(check well use): 0.0 rt. 38.0 ft- 1.0 in. SCH 40 PVC
Water Supply Well: 17.SCREEN...
FROMTO DIAMETER SLOTSIZE THICKNESS MATERIAL
DAgricultural E]Municipal/Public 58.0 ft' 60.0 ft' 1.0 in. .010 SCH 40 PVC
ElGeothermal(Heating/Cooling Supply) EiResidential Water Supply(single) 38.0 rt. 40.0 ft' 1.0 in' .010 SCH 40 PVC
01ndustrial/Commercial oResidential Water Supply(shared) 18.GROUT
oIrrigation oWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 35.0 rt. PORTLANC;BENTONFrE
SLURRY
[EMonitoring 0 Re6overy ft. ft.
Injection Well: ft. ft.
EJ Aqui fer Recharge 0 Groundwater Remediation 19.SANDIGRAVEL PACK(ifapplicable),
0 Aquifer Storage and Recovery E]Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
0Aquifer Test 0 Stormwater Drainage 57.0 "- 60.0ff 20-40 FINE SILICA SAND
DExperi mental Technology 0 Subsidence Control 37.0 ft- 40.0 ft. 20-40 FINE SILICA SAND
DGeothermal(Closed Loop) ElTracer 20.,DRILLING LOG attach additional sheets if necessary), -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.)
ElGeothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) 0.0 ft. 1.0 1'. GRASS/TOPSOIL
4.Date Well(s)Completed: 1 1/1 0/22 W,111D# BS-6-B/A 1.0 22.0 BROWN CLAY
5a.Well Location: 22.0 50.0 ft' BROWN SILT
GLIDDEN COMPANY 50.0 f- 60.0 1- GRAY SILTY PWR
Facility/OwnerNarne ft.
Facility ID#(if applicable)
3926 GLENWOOD'DRIVE CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip ft. ft.
MECKLENBURG ILRENIARKS
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
(ifwell field,one fat/long is sufficient) 22.Certification:
350 15' 00.27" N 800 53' 06.04" W A4ri,,,l�,; r 11/30/22
6.Is(are)the well(s): [EPermanent or OTemporary Signature of Certified Well Contractor : Date
By signing this form,lhereby certify that the wells)was(were)constructed in accordance with
7:Is this a repair to an existing well: ElYes or (ENo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature oflhe 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 I GW-I 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: 60.0/40.0 _(ft.) Submit this GW-1 within 30 days'of well completion per the following:
For multiple wells list all depths ifilifferent(example-3@200'atid2@100')
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
Ifivaler 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 departinent of the county where installed
FOR WATER SUPPLY WELLS ONLY: I :
24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Forin GW-1 North Carolina Department of Environmental Quality-Division of Water Resources• Revised 6-6-2018