GW1-2023-00929_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORDOnly: - -.GW-1 For Internal Use
1.Well Contractor Information:
JOHNNY BURR
14.WATER ZONES' r 1
Well Contractor Name FROM TO I DESCRIPTION
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 MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loon)
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 ft• 70.0 fr• 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 70.0 fr, 80.0 fr' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Ind ustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 ft- 66.0 ft' PORTLANDBENTONITE SLURRY
ITMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 68.0 ff• 80.0 ff• 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/rock type,ginin size,etc.
0.0 ff• 22.0 1" CONCRETE
4.Date Well(s)Completed: 12/02/22 Well ID# MW-B21-14I 220 ff• 36.0 ff• RED CLAY
5a.Well Location: 36.0 ff• 60.0 fL TAN SILTY CLAY
COPES - VULCAN 60.0 ff• 80.0 ff• TAN PWR
Facility/Owner Name Facility lD#(ifapplicable)
601 WEST SUMMIT AVENUE CHARLOTTE 28203
Physical Address,City,and Zip ft. fr.
MECKLENBURG 21.REMARKS '
Cowrty Parcel Identification No.(PIN) BENTONITE SEAL-66.0-68.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ha/long is sufficient) 22.Certification:
350 13' 17.12" N 800 51' 50.23" W ?-0--7/ �15 14-' 12/28/22
6.Is(are)the well(s): OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(here)constructed in accordance with
7.IS this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe oflhis record has been provided to the well 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: 80.0 (ft.)
For multiple wells list all depths ifdierent(example-3 a200'and 2@1000 Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 33•0 (ft.) Information
For All Wells: Original form to Division of Water Resources (DWR),
If,valer level is above casing,use"+'• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
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:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018