GW1-2023-00927_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORD GW-1 For Internal Use Only: ^ r;•
1.Well Contractor Information: JA� 2 O ,
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION r "'•yo);;';,
A - 3098 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if a tlicable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit li: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perntits(i.e.VIC,County,Stale,Variance,etc.) 0.0 ft• 22.0 ft. 2.0 1O' SCH 40 PVC
3.Well Use(check well use): ft. 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
❑lrrl ation ❑Wel Is>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 fL 18.0 ft' PORTLANDBENTONITE SLURRY
INMonitoring ❑Recovery rt. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a t tlicablc
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEIIIENT METHOD
❑Aquifer Test ❑StonmwaterDrainage 20.0 ft. 32.0 ft' 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer '20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type,gmin size,etc.
0.0 ft• 20.0 It. BROWN SILTY CLAY
4.Date Well(s)Completed: 1 1/21/22 Well ID# MW-B16-5I 20.0 ft• 32.0 ft- BROWN/GRAY PWR
Sa.Well Location: ft. ft.
COPES - VULCAN ft. ft.
Facility/Owner Naune Facility ID#(if applicable)
601 WEST SUMMIT AVENUE CHARLOTTE 28203 ft. ft.
Physical Address,City,and Zip rt. ft.
MECKLENBURG 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 latllong is sufficient) 22.Certification:
350 13' 17.12" N 800 51' 50.23" W ) `' 12/28/22
6.Is(are)the well(s): IEPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)construcled in accordance with
7.Is this a repair to an existing well: ❑Yes or I9No 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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 been provided to the well owner.
repair under#21 renrarkr 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 I 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 multiple wells list all depths ifdierent(example-3 rt 200'and 2 tl 100') 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),
Ijf Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
waler 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
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Font OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018