GW1-2023-00860_Well Construction - GW1_20230112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
KENNY SARGENT 14.WATER ZONES s
Well Contractor Name ' r ice,,,5 FROM TO DESCRIPTION
I N 2023 fr. ft. t �
NC Well Contractor Certification Number J A I V 15.OUTER CASING for multi-cased OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
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Company Name "" "'- r r, r, i t7 ft. ft. in.
' °a 16.INNER CASING OR TUBING eothermal closed-loop
2.Well Construction Permit#: FROM I TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits#.e.UIC,County,State,Variance,etc.) 0.0 ft. 58.0 ft- 1.0 in. SCH 40 PVC
3.Well Use(check well use): 0.0 It. 38.0 ft- 1.0 in. SCH 40 PVC
Water Supply Well: 17.SCREEN '
FROM TO DIAMETER SLOTSIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 58.0 ft' 60.0 1" 1.0 in.
.010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 38.0 ft 40.0 ft• 1.0 in• .010 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL ENI PLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 35.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a nlicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 57.0 ft- 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)
FROM TO DESCRIPTION color,hardness,soilt rock e, actin siu,etc.)
❑Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks)
0.0 ft• 1.0 ft• GRASSfIOPSOIL
4.Date Well(s)Completed: 11/08/22 Well ID# BS-15-B/A 1.0 ft• 22.0 ft• BROWN CLAY
5a.Well Location: 22.0 ft• 50.0 ft' BROWN SILT
GLIDDEN COMPANY 50.0 ft 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.
M ECKLEN BU RG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-40.0-57.0 FEET&35.0-37.0 FEET
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***NESTED WELLS
(ifwell field,one lat/long is sufficient) 22.Certification:
350 15' 00.27" N 800 53' 06.04" W #WW'd, � 11/30/22
6.Is(are)the well(s)• [EPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(here)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 01C.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 ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or an 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.)
For au/tiple wells list al/depths ifdii ferent(example-3Ca 200'and 2 100') Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 40.0 (ft) 24a. For All Wells: Original form:to Division of Water Resources (DWR),
Iftrater level is above casing,use"+"
Information Processing Unit,1617 MS I C,'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-Lo'ooGeothermal 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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC,27699-1611
13b.Disinfection type: Amount:
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Form GW-1 North Carolina Departmenit of Environmental Quality-Division of Water Resources Revised 6-6-2018
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