GW1-2023-00926_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: A N 9 ^
JOHNNY BURR 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION =•i.F3;l
A - 3098 ft. ft.
LNI"Q� w. "gunk,
ft. ft.
NC Well Contractor Certification Number I5.OUTER CASING for multi-cased wells OR LINER if a ilicable)
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 I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft. 25.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. rt. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agrictlltttral ❑Municipal/Public 25.0 ft' 3S.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
[Irrigation ❑Wet Is>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD B AMOUNT
Non-Water Supply Well: 0.0 ft' 21.0 fL PORTLANDBENTONITE SLURRY
[EMonitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a I ilicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT MET1101)
❑Aquifer Test ❑Stormwater Drainage 23.0 ft. 35.0 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 type, ITin size,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks)
0.0 ft• 20.0 ft. BROWN ROCKY SILTY CLAY
4.Date Well(s)Completed: 11/21/22 Well ID# MW-B16-2I 20.0 fr. 35.0 ft• BROWN/GRAY PWR
5a.Well Location:
rt. ft.
COPES - VULCAN ft. ft.
Facility/Owner Name Facility ID#(if applicable)
601 WEST SUMMIT AVENUE CHARLOTTE 28203
Physical Address,City,and Zip
ft. ft.
MECKLENBURG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-21.0-23.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: �1
35e 13' 17.12" N 80e 51' 50.23" W 12/28/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(here)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
1J7his is a repair,Jil/out known use//construction information and explain the nature of the of this record has been provided to the well owner.
repair under 921 remarks section or or the back ofthis form.
23.Site diagram or additional well details:
8.For Gcoprobe/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: 35.0 (ft.)
For nnrltiple wells list all depthsifdW&rent(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
23.0 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
IJ'Iraier level is above casing,use'•+"
11.Borehole diameter: 8.0 (in,) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,]636 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) A4ethod of test: Penn it Program, 1611 MSC,Raleigh,NC 27699-161 1
13b.Disinfection type: Amount:
Fomi GW-I North Carolina Department of Envirommental Quality-Division of Water Resources Revised 6-6-2018