GW1-2023-00934_Well Construction - GW1_20230120

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: �* b
1.Well Contractor Information: JAN 2
JOHNNY BURR 14.WATER ZONES n ,• "
FROM TO DESCRIPTION U
Well Contractor Name (^^?^,min
rt. ft. ,rQ•3`G n t
A - 3098
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a slicable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
fr. fr. i".
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.UIC,County,State,Variance,etc) 0.0 ft• 50.0 ft• 2.0 '"' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS DIATERIAL
❑Agricultural ❑Municipal/Public 50.0 It- 60.0 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 ❑Wells>100,000 GPD FROM TO DIATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0.0 rt 46.0 rt' PORTLANDBENTONITE SLURRY
l0lMonitoring ❑Recovery
Injection Well:
rt. rt.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if a n licahle
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StortnwaterDrainage 48.0 ft- 60.0 ft 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control Pt. ft.
❑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/mck type,ginin sim,ere.
0.0 ft 25.0 f` CONCRETE
4.Date Well(s)Completed: 12/08/22 Well ID# MW-B13-32I 25.0 1t. 50.0 r`' TAN SILTY CLAY
5a.Well Location: 50.0 f`' 60.0 TAN PWR
COPES - VULCAN rt. ft.
Facility/Owner Name Facility ID#(ifapplicable) fr. ft.
601 WEST SUMMIT AVENUE CHARLOTTE 28203 ft. ft.
Physical Address,City,and Zip ft. ft.
MECKLENBURG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL• 46.0-48.0 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' S0.23" W '� 12/28/22
6.is(are)the well(s): INPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,]hereby certify that the Irell(s)was(were)constructed in accordance Iridt
7.Is this a repair to an existing well: ❑Yes or MNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
/f this is a repair,Jill out knolrn well construction information and explain the nature ofthe ofthis record has been provided to the bell oumer.
repair under#21 remarks section or on the back of this forms.
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: 60.0 (ft.)
1%or multiple wells list all depths ifdi,Jferent(example-3 r@r 200'and 2 rr 100') Submit this GW-1 within 30 days of well completion per the following:
28.0 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
Ifivater level is above casing,use"+"
11.Borehole diameter: 8.0 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(]UC)
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
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018