GW1-2023-00855_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.,WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
A - 4226
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for 0 livable
GEOLOGIC EXPLORATION FROM DIAMETER THICKNESS MATERIAL
Company Name JAN f. ft. I ; I
'16.INNER CASINGOR.TUBING(geoth6rmal closed-loop)
un I FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
List all applicable well construction permits(i.e.UIC,County, 0.0 ft- 58.0 ft- 1.0 in. SCH 40 PVC
3.Well Use(check well use): 0.0 ft- 38.0 ft- 1.0 in. SCH 40 PVC
17.SCREEN,
Water Supply Well: FROM TO DIAMETER'. SLOT SIZE THICKNESS MATERIAL
oAgricultural OMunicipal[Public 58.0 1" 60.0 ft' 1.0 in.' .010 SCH 40 PVC
DGeothermal(Heating/Cooling Supply) oResidential Water Supply(single) 38.0 ft- 40.0 ft' 1.0 in. .010 SCH 40 PVC
E]Industrial/Commercial oResidential Water Supply(shared) I 8..GROUT
oIrrigation OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 35.0 ft- PORT LANO BIENTONITE SLURRY
[IflMonitoring DRecovery ft. ft.
Injection Well: ft. ft.
El Aquifer Recharge 0 Groundwater Remediation
r19:SAND/GRAVEVPAC (ifatitilkable).,'.
•Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•Aquifer Test oStormwater Drainage 57.0 60.0 20-40 FINE SILICA SAND
DExperimental Technology oSubsidence Control 37.0 40.0 ft- 20-40 FINE SILICA SAND
.
DGeothermal(Closed Loop) oTracer 20.DRILLING LOG(attach additibnalsheets ifnecessarty) __
DGeothermal(Heating/Cooling Return) ClOther(explain under 921 Remarks)] FROM TO DESCRIPTION(color,hardness,sail/rock type,ginin size,etc.)
0.0 1.0 It. GRASS,/TOPSOIL
4.Date.Well(s)Completed: 11/09/22 Well ID# BS-9-B/A 1.0 22.0 f" BROWN CLAY
ft
5a.Well Location: [2g2.0 't- 50.0 It- BROWN SILT
ft
GLIDDEN COMPANY 50.0 60.0 f" 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,
County Parcel Identification No.(PIN) BENTONITE SEAL-40.0-57.0 FEET&35.0-37.0 FEET
***NESTED WELLS
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifivell field,one fat/long is sufficient) 22.Certification:
350 15' 00.27" N 800 53' 06.04" W 11/30/22
6.Is(are)the well(s): [EPermanent or oTemporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the ivell(s)ivas(Were)constructed in accordance with
7.Is this a repair to an existing well: 0Yes or MNo 15A NCAC 02C.0100 or IJA NCAC 02C.0200 Well Construction Standards and that a cop),
If this is a repair,fill out knoun ivell construction information and explain the nature of the ofthis record has been provided to the ivell 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 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 ifdifferent(example-3@200'and 2@100')
40.0 24a. For All Wells: Original forin 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 water level is above casing,use
11.Borehole diameter: 8.0 (in.) 24b.For Injection Wells: Copy to,�DWR,Underground Injection Control(fUC)
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:
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources rf
Revised 6-6-2018