GW1-2023-00862_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.WATER ZONES 1 I
Well Contractor Name FROM TO DESCRIPTION
A - 4226 t :��� ` ✓
ft. ft.
JAN � v
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NC Well Contractor Certification Number P 2923 15.OUTER CASING for multi-cased iv OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER ells I THICKNESS MATERIAL
ft. ft. in.
Company Name
p y 16:INNER CASING OR TUBING eothermat closed-loop)2.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) 0.0 ft. 57.0 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
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER-L SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 57.0 ft' 59.0 ft' 1.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) 38.0 B- 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 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 35.0 ft' PORTLANDBENTONITE SLURRY
1!9Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL'PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Storinwater Drainage 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#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltroch type,grain size,etc.
0.0 ft. 1.0 ft. GRASS/TOPSOIL
4.Date Well(s)Completed: 1 O/27/22 Well ID# BS-17-B/A 1.0 ft. 22.0 ft. BROWN CLAY
• Sa.Well Location:
22.0 fL 50.0 ft' BROWN SILT
GLIDDEN COMPANY 50.0 ft. 59.0 ft. GRAY SILTY PWR
Facility/Owner Name Facility ID#(if applicable) ft. ft. f
.3926 GLENWOOD DRIVE CHARLOTTE 28208 ft. ft.
'Physical Address,City,and Zip ft. ft.
M EC KLE N B U RG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-40.0-56.0 FEET&35.0-37.0 FEET
***NESTED WELLS***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
350 15' 00.27" N 800 53' 06.04" W .#yl,l,,,�A.,-_- 11/30/22
6.Is(are)the well(s): (TPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,]hereby certify that the we//(s)ivas(were)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
If this is a repair,fill out known well construction information and explain the nature of the ofthis record has been provided to the well owner.
repair under 421 remarks section or on lite 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',
00/40.
9.Total well depth below land surface: 59. (ft.) Submit this GW-1 within 30 days ofwell completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100)
40.0 24a. For All Wells: Original form 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(IUC)
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 27699-1 61 1
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