GW1-2023-00854_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
ft. ft.
A - 4226
NC Well Contractor Certification Number ----,c ' '' '."2
'k IY, -vl­a tr; S 15.OUTER CASING for multi-cased'wells OR LINER if a hHcable
GEOLOGIC EXPLORATION FROM TO DIAMETERi THICKNESS MATERIAL
ft. ft. in.
Company Name S v J
16.INNER CASING OR TUBING 'eothermal closed-loop),
2.Well Construction Permit#: h O, r onnio n l h '! FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constructionperoits(i.e. C,CounryrSsate„Yarmpee,eic.) O.O fr' 58.0 fr' 1.O in. 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 ft. 60.0 ft. 1.0 in: .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 38 ft. 40.0 ft' 1.0 1O' 010 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 35.0 ft. PORTLAND,BENTONITE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well:
fr. fr.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
[]Aquifer Test ❑Stormwater Drainage 57.0 ft• 60.0 fc 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 421 Remarks) FROM To DESCRIPTION color,hardness,soillmck type,gnain size,etc.
0.0 ft. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 11/08/22 Well ID# BS-8-B/A 1.0 fr• 220 rt, BROWN CLAY
Sa.Well Location: 22.0 ft• 50.0 ft' BROWN SILT
GLIDDEN COMPANY 50.0 rt• 60.0 ft• GRAY SILTY PWR
'Facility/Owner Name Facility ID#(if applicable) ft. ft.
3926 GLENWOOD DRIVE CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip ft. ft.
MECKLENBURG' '21;REMARKS' 2 '
County Parcel Identification No.(PIN) BENTONITE SEAL-40.0-57.0 FEET&35.0-31.0 FEET
`**
Sb...Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***NESTED WELLS
(if well field,one lat/long is sufficient) 22.Certification:
350 15' 00.27" N 800 53' 06.04" W I,uj 1,,,,,1st,; ,-� 11/30/22
6.Is(are)the well(s)• TPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 15No I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ropy
lfthis it a repair,fill out known ivell construction information and explain the nature of the of this record has been provided to lire well owner.
repair under 921 rennarks section or on the back ofthis 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 (ft)
For multiple wells list all depths ifdierent(example-3(a 200'and 2 a 100) Submit this GW-1 within.30 daysbf 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
Ifwater 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-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
t
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program, 1611 MSC,Raleig I h,NC 27699-1611
13b.Disinfection type: Amount:
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018