GW1-2023-00856_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
KENNY SARGENT 14.WATERZONEs t.
Well Contractor Name FROM TO--.I DESCRIPTION
A - 4226
NC Well Contractor Certification Number 15.OUTER CASING•for ruulti-casedlwclls OR LINER if a licable
GEOLOGIC EXPLORATION JAN j 19 2023 FROM TO DIAMETER THICKNESS M1fATERIAL
ft. rt. � in.
Company Name
E llwii; 'I 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: r;z- y;v FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable hell construction permits(i.e.UIC,County,Slate,Variance,etc.) 0.0 ft• 58.0 ft. 1.0 '"' SCH 40 PVC
3.Well Use(check well use): 0.0 ft. 38.0 It. 1.0 '"' SCH 40 PVC
Water Supply Well: 17.SCREEN'
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 58.0 fr. 60.0 ft' 1.0 in. .010 SCH 40 PVC .
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 38 0 fr, 40.0 fL 1.0 in. .010 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 35.0 ft. PORTLANDBENTONITE SLURRY
INIMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier19.SAND/GRAVEL PACK if alicableier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 57.0 1" 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 I TO DESCRIPTION color,hardness,soil/rock type,ginin size,etc.
0.0 It. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 11/09/22 Well ID# BS-10-B/A 1.0 1t• 22 0 ft• BROWN CLAY
Sa.Well Location: 22.0 ft. 50.0 f" BROWN SILT
GLIDDEN COMPANY 50.0 ft• 60.0 ft• GRAY SILTY PWR
` Facility/Owner Name Facility ID#(if applicable) ft. ft. f `-
3926 GLENWOOD DRIVE CHARLOTTE 28208 ft. fr.
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG 21.REMARKS
Comity Parcel Identification No.(PIN) BENTONITE SEAL-40.0-57.0 FEET&35.0-37.0 FEET
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
***NESTED WELLS***
(ifwell field,one lat/long is sufficient) 22.Certification:
35e 15' 00.27`' N 800 53' 06.04" W 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 dvell(s)Bras(here)constructed in accordance truly
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out knoum hell construction information and explain the nature ofthe ofthis record has been provided to rite hell oumer.
repair under 921 remarks 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 I 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: 60.0/40.0 (ft.)
1•or tnultiple uve/ls list all depths ifelifferent(example-3(7a 200'and 2 a 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),
If hater/ernel is above casing,use
f Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
"+" �
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-L!oop 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,iNC 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 Revised 6-6-2018
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