GW1-2023-00932_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: AN 9
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JOHNNY BURR 14:WATERZONES r c?
Well Contractor Name FROM TO DESCRIPTION
A - 3098 'J'�."Ya Urm
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased Nclls OR LINER if a rlicable)
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
fit. ft. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable trel/construction permits(i.e.U/C County,State,Variance,etc.) 0.0 ft. 3.0 fit' 2.0 in' SCH 40 PVC
3.Well Use(check well use): tr. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3.0 ft' 8.0 ft' 2.0 "' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. I ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 1.0 ft' PORTLAND BENTONITE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Rernediation
19.SAND/GRAVEL PACK(ifa licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StonnwaterDrainage 2.0 it. 8.0 fir• 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft. I +
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#2.1 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, inin size,etc.)
0.0 fit• 4 0 fit• RED/ORANGE CLAY
4.Date Well(s)Competed: 12/19/22 Well ID# MW-BG-B23S 4.0 fit• 7.0 fit• TAN PWR
5a.Well Location: 7.0 ft' 8.0 rt. GRAY ROCK
COPES - VULCAN ft. ft.
-- Facility/Owner Name _ ---�-- Facility ID#(ifapplicable) ft. ft. -- - - ---- -- --- _- - - -
601 WEST SUMMIT AVENUE CHARLOTTE 28203 ft. ft.
Physical Address,City,and Zip
tr. ft.
MECKLENBURG 21.REMARKS
County Parcel identification No.(PIN) BENTONITE SEAL- 1.0-2.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
350 13' 17.12" N 800 51' 50.23" W i n 12/28/22
6.Is(are)the well(s): 149Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the irell(s)iras•(were)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
Ifthil•is a repair,fill out knolrn ivell constriction information and explain the nature of the ofihis record has been provided to the irell orner.
repair under#21 remarks section or on the back oJ'1his Jornn.
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: 8.0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple tre//s list all depths ifdiJJereni(example-3@200'and 2@100)
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
Iftrater 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-Loon 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:
Fonn GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018