GW1-2023-00925_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: 'IN 4
JOHNNY BURR 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
A - 3098
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mulfi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS 11fATER1AL
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(i.e.UIC,County,State,Variance,etc.) 0.0 ft. 32.0 ft. 2.0 in' 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 ❑MunicipaVPublic 32.0 ft- 42.0 ft' 2.0 1n. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑frrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUN'r
Non-Water Supply Well: 0.0 ft. 28.0 ft' PORTLANDBENTONITE SLURRY
OMonitoring ❑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 ❑StormwaterDrainage 30.0 ft• 42.0 ft• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control
❑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/mck type,grain sim etc.
0.0 fr• 10.0 fr• RED CLAY
4.Date Well(s)Completed: 12/02/22 Well ID# MW-B13-39I 10.0 fr• 23.0 f` TAN SILTY CLAY
5a.Well Location: 23.0 ft• 42.0 ft' TAN PWR
COPES - VULCAN ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
601 WEST SUMMIT AVENUE CHARLOTTE 28203
Physical Address,City,and Zip ft. ft.
MECKLENBURG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-28.0-30.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/long is sufficient) 22.Certification:
350 13' 17.12" N 800 51' 50.23" W 12/28/22
6.Is(are)the we11(s): [EPermanent or []Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance wick
7.Is this a repair to an existing well: ❑Yes or [ENo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standarr6 and that a copy
If this is a repair•fill out known well construction information 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ove?in Remarks Box).You may also attach additional pages if necessuy.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 42.0 (ft.)
For multiple wells list all depths irdiJferent(example-3 tt 200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
20.0 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
Ifwater 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: 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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018