GW1-2023-00861_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'- ;g`
Well Contractor Name FROM TO DESCRIPTION
ft. ft. I '
A - 4226 ri'-`' �� �- . .
NC Well Contractor Certification Number '
15.OUTER CASING for multi-cased.Wells OR LINER if a licable
GEOLOGIC EXPLORATION JA�i y ���� FROM TO DIAMETER ; THICKNESS MATERIAL
ft. ft. I in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loo
J ,S
2.Well Construction Permit#: rl x•->••�;r�r FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stteite,YaFtance,etc.) 0.0 ft• 58.0 fL 1.0 1°' 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 I .:,;,
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
'El Agricultural ❑Municipal/Public 58.0 ft• 60.0 ft• 1.0 in. .010 SCH 40 PVC
❑.Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 38.0 tt. 40.0 ft' 1.O in. 010 SCH 40 PVC
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 35.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑Recovery ft. ft. i
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SANDlGRAVEL'PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stonmwater Drainage 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,soilhrock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 1.0 It. GRASS/TOPSOIL
4.Date Well(s)Completed: 11/07/22 we111D# BS-16-B/A 10 ft• 220 ft• BROWN CLAY
5a.Well Location: 22.0 fL 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. 4
3926 GLENWOOD DRIVE CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip
ft. ft.
M ECKLEN BU RG 31.'REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-40.0-57.0 FEET&35.0-37.0 FEET
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Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ***NESTED WELLS
(if well field,one latllong is sufficient) 22.Certification:
350 15' 00.27" N 800 53' 06.04" W A41- 1d,4-� 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'trel/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MNo I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
1f this is a repair,fill out known we//construction information and explain the nature of the ofthis record has been provided to the ire/1 oirner.
repair under#21 remarks section or on the back ofthis farm.
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 t6 provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovet'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
00/40.
9.Total well depth below land surface: 60. (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifd(�erent(example-3 ri)200'and 1 rr 100')
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10.Static water level below top of casing: 40•0 (ft) 24a. For All Wells: Original form �ko Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" L
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(TUC)
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 ovelr 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: �I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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