GW1-2023-00858_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATERZONES I
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Well Contractor Name (_ ,, 7-, 1 a-,, FROM TO DESCRIPTION
•`' 4e+Tn
A - 4226
fr. ft. f
NC Well Contractor Certification Number JA N 1 v 2023 15.OUTER CASING for mu1H-cascdawells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER f THICKNESS MATERIAL
Ind^r-- ice-. •."f.,...�✓v'- i ft. ft. I in.
Company Name
J tiu.i
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 fL 57.0 ft- 1.0 in' SCH 40 PVC
3.Well Use(check well use): 0.0 H- 38.0 ft- 1.0 in. SCH 40 PVC
Water Supply Well: 17:SCREEN,
FROM TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 57.0 I'L 59.0 ft' 1.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 38.0 f" 40.0 ft, 1.0 in, ,010 SCH 40 PVC
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Welis>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 35.0 ft' PORTLANDBENTONITE SLURRY
MMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 56.0 ft- 59.0 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 421 Remarks) FROM I TO DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
0.0 ft. 1.0 ft' GRASS/TOPSOIL
4.Date Well(s)Completed: 11/01/22 Well ID# BS-13-B/A 1.0 ft- 22.0 fL BROWN CLAY
Sa.Well Location: 22.0 ft' 50.0 ft- BROWN SILT
GLIDDEN COMPANY 50.0 ft• 59.0 ft• GRAY SILTY PWR
Facility/Owner Name Facility ID4(if applicable) `-
3926 GLENWOOD DRIVE CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-40.0-56.0 FEET&35.0-37.0 FEET
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5b.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 4rn 11/30/22
6.Is(are)the well(s): 091'ermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certl&that the well(s)was(here)constructed in accordance with
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
lfthis is a repair,fill out known well construction information and explain the nature ofdte ofthis•record has been provided to rite well owner.
repair under#21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
S.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 Over in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 59.0/40.0 (ft)
For multiple wells list all depths ifdiereni(example-3@a 200'and 2@100') Submit this GW-1 within 30 days of'well completion per the following:
10. 40.0 24a. For All Wells: Original form Ito Division of Water Resources (DWR),
fwater level is abore casing,use Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: 8.0 (in,) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27d94-1636
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: 1
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018