GW1-2023-00930_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: (r ''
1.Well Contractor Information: •
_ t
JOHNNY BURR
14.WATER ZONES 14J
Well Contractor Name FROM TO DESCRIPTION _
ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-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-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,Canny,State,Variance,etc.) 0.0 fl• 45.0 ft. 2.0 'n' SCH 40 PVC
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 45.0 f`' 55.0 rt• 2.0 in' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.18.GROUT
❑Irrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 41.0 ft- PORTLANDBENTONITE SLURRY
INMonitoring ❑Recovery ft. ft.
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 43.0 ft. 55.0 f`. 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)
0.0 ft- 23.0 f`• CONCRETE
4.Date Wells)Completed: 11/28/22 Well ID# MW-B21-145 23.0 ft- 35.0 ft- RED CLAY
5a.Well Location: 35.0 f` 50.0 f`' TAN SILTY CLAY
COPES - VUL_CAN 50.0 ft 55.0 ft TAN PWR
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
601 WEST SUMMIT AVENUE CHARLOTTE 28203
Physical Address,City,and Zip ft. ft.
M ECKLEN B U RG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-41.0-43.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 13' 17.12" N 800 51' 50.23" W 12/28/22
(71
6.Is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify Thal the we//(s)was(here)constructed in accordance wish
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a copy
Iflhis is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under 921 remarks section or at 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: 55.0 (ft.)
For mu/liple wells list all depths ifdii ferew(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
33.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
f Static water level below top of casing: (ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ljwater lore/is above caring,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 27699-161 l
13b.Disinfection type: Amount:
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018