GW1-2023-00865_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
KENNY SARGENT 14.WATERZONES i
Well Contractor Name FROM TO DESCRIPT I ION
ft. ft.
A - 4226
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION r ' +^ h,Vry jPY `s; FROM TO DIAMETER THICKNESS MATERIAL
� ft. ft. in.
Company Name (11�
2.Well Construction Permit#: J A"+j�I� A 2 2O23 FROM16. NE TO R CASING OR TU DIAMETER
ING hermalTHICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance, ir 0.0 ft- 58.0 ft. 1.0 in.
em SCH 40 PVC
3.Well Use(check well use): c,
ill ,�i7::�µ^i1: FROM
ft. 38.0 ft. 1.0 in. SCH 40 PVC
y?�7
Water Supply Well: _SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 58.0 f" 60.0 ft' 1.0 7°' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) El 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
❑lrri ation ❑Wells>100,000 GPD FROM 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.
El Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRANGE PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 57.0 fL 60.0 fL 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,soil/rock type,grain sin,etc.
0.0 ft- 1.0 ft• GRASS/TOPSOIL
4.Date Well(s)Completed: 11/21/22 well ID# BS-25-B/A 1.0 ft. 220 ff- 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#(ifapplicabl) ft. ft.
3926 GLENWOOD DRIVE CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip ft. ft.
M ECKLEN B U RG 21.REMARKS
County Parcel Identification No.(PIN) BENTONIfE SEAL-40.0-57.0 FEET&35.0-37.0 FEET
*** ***
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 #6�� '' 11/30/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,]hereby certify that the well(s)was(were)consiructed in accordance with
7.Is this a repair to an existing well: ❑Yes or INNo 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 peen provided to the well owner.
repair under#21 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 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: 60.0/40.0 (ft.)
For inultiple wells list all depths ifdii Brent(example-3@200'and 2@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),
10.Static water level below top of casing: A) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1f 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 producinglov'er 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-1 North Carolina Department of Environmental Quality-Division of Water Resources) Revised 6-6-2018
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