_Well Construction - GW1_20230310 (5)

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 3098
B. a.
NC Well Contractor Certification Numberrn; 7 7 15.OUTER CASING for multi-cased wells OR LINERlicable
GEOLOGIC EXPLORATION M�'" Y n `� FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING ORTUBING(geothermal closed-loop)
2.Well Construction Permit#:
v'S5 tom)/ %'..'L` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C.County,State,Variance,etc.) 0.0 ft. 35.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): rt. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 35.0 ft. 45.0 ft. 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri atlon ❑Wells>100 000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 O• 31.0 fL PORTLANDaENTONITE SLURRY
❑Monitoring ❑Recovery ft. fL
Injection Well:
❑Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL
fL
PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 33.0 ft. 45.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology []Subsidence Control B. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wil/mck type,train siw,etc.
0.0 ft. 15.0 ft. CONCRETE/BRICK BACKFILL
4.Date Well(s)Completed: 02/10/23 NN'ell ID# IW-13-24B 15.0 ft- 23.0 ft- RED/ORANGE CLAY
5a.Well Location: 23.0 fl- 45.0 ft' TAN SILTY CLAY
COPES - VULCAN ft. ft.
Facility/Owner Name Facility ID#(if applicable) rt. rt.
601 WEST SUMMIT AVENUE CHARLOTTE 28203 ft. ft.
Physical Address.City,and Zip ft. ft.
M ECKLE N BU RG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-31.0-33.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification:
350 13' 17.12" N 800 51' 50.23" W �'�'t"� 02/21/23
6.Is(are)the well(s): MPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or 19No ISA 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 of this 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 Ceoprobe/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 GWA is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 45.0 (ft.)
For multiple wells list all depths q'di,(jerem(example-3@200'and 1@100) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 30.0 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
if ivater 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 Su I and O en-Lao Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county envlronmenta health department o e county where Insta ed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test:
Permit Program,1611 MSRaleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018