GW1-2023-00922_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: `
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION ►tvUfT Kra„+^; j� .`.,
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A - 3098 G..�, ,"
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a llicable
GEOLOGIC EXPLORATION FROM To DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal 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 rt• 22.0 rt. 2.0 '"• SCH 40 PVC
3.Well Use(check well use): 1t. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 22.0 It' 32.0 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) 18.GROUT
❑Irrt atlon ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft' 180 ft- PORTLANDBENTONITE SLURRY
INMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 20.0 IL 32.0 IL 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,soiltrock type, rain sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 rt• 8.0 rt• GRAVEL
4.Date Well(s)Completed: 12/01/22 Well ID# MW-B13-375 8.0 rt. 11.0 rL RED CLAY
Sa.Well Location: 11.0 It. 22.0 n' BROWN SANDY CLAY
COPES - VULCAN 22.0 ft. 32.0 ft. BROWN PWR
Facility/Owner Name Facility ID#(if applicable) ft. It.
601 WEST SUMMIT AVENUE CHARLOTTE 28203 ft. ft.
Physical Address,City,and Zip
f[. ft.
M ECKLEN BU RG 21.REMARKS
County Parcel Identification No.(PIN)
BENTONITE SEAL- 18.0-20.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(ifwell field,one lat/long is sufficient) 22.Certification:
350 13' 17.12" N 800 51' 50.23" W �"'Y`� 12/28/22
6.Is(are)the well(s): 129Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the trell(s)was(here)construcled in accordance with
7.Is this a repair to an existing well: ❑Yes or [5No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,Jill out known well construction inforntalion and explain the nature of the of this record has been provided to the well owner.
repair under 921 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 l 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: 32•0 (ft.)
For mulliple wells list a//depths ifdierent(example-3 a 00'and 2@100')10. Submit this GW-1 within 30 days of well completion per the following:
26.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifwater level is above casing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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11.Borehole diameter: 8.0 (ill.) 24b. For Injection Wells: Copy to 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
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:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018