GW1-2023-00866_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
CARL CARPENTER 14.WATER ZONES 1
Well Contractor Name FROM TO DESCRIPTION
A - 4475 -4° '� ft.
�
NC Well Contractor Certification Number (� 15:OUTER CASING for multi-cased'wells OR LINER if a licable
GEOLOGIC EXPLORATION JAN i v 2Q23 FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name `i _j ;)t .+ 16.INNER CASING OR TUBING cother at closed-loop)
2.Well Construction Permit# s r,�'s�UiS'•Jt� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable trel/construction pernins(i.e.UIC,County,State,Variance,etc) 0.0 ft. 16.0 ft. 2.0 '"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 16.0 ft' 31.0 ft. 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft, 12.0 ft' PORTLANDSENTONRE SLURRY
Monitoring ❑Recovery ft. fr.
Injection Well:
ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation
„19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 14.0 ft, 31.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer .20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 ft• 1.0 ft• TOPSOIL
4.Date Well(s)Completed: 11/08/22 Well ID# MW-23 1.0 ft• 15.0 ft' RED CLAY
ia.Well Location:
15.0 ft• 31.0 f" TAN SILTY CLAY
LUNDY/TRANSTECHNOLOGY ft. fr.
Facility/Owner Name Facility ID#(if applicable) ft. ft. `
5535 WILKINSON BLVD CHARLOTTE 28208
Physical Address,City,and Zip ft. ft.
M ECKLEN BU RG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL- 12.0-14.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: _
350 13' 53.29" N 800 55' 53.98" W 1 �
12/01/22
6.Is(are)the well(s): ONPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this•form,I hereby certify that the well(s)was(were)constructed in accordance frith
7.Is this a repair to an existing well: ❑Yes or I19No 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
tf this is a repair,fill out known well construction information and explain the nature of the oJ7his record has been provided to the irell owner.
repair under#21 remarks section or on 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 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: 31.0 (ft)
1%or multiple use/Ls list all depths ifdii ferent(example-3 vet 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: 24.0 (ft) 24a• For All Wells: Original form to Division of Water Resources (DWR),
/f water/eve/is above casing,use op Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
il.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy toi DWR,Underground Injection Control (IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER 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
i
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: F
13b.Disinfection type: Amount: I
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018