_Well Construction - GW1_20230310 (8)

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
m, ft. ft.
NC Well Contractor Certification Number `ire •`'x_ - ` 1
15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION MAR ? �n� FROM TO DIAMETER THICKNESS MATERIAL
MAR ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: .^) ;''- t";'� I_!( ,j FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,Coumy,Stare,Variance,etc.) 0.0 rt. 25.0 rt' 2.0 '"' SCH 40 PVC
3.Well Use(check well use): ft. re. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 ft• 35.0 rt• 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
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 n- 21.0 rt• PORTLANDBENTONnt SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well:
rt. rt.
❑Aquifer Recharge 19Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage 23.0 ft 35.0 n 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,soiltrock tyM gmin size,etc.
0.0 rt• 15.0 ". CONCRETE/BRICK BACKFILL
4.Date Well(s)Completed: 02/10/23 NVell ID# IW-13-24A 15.0 rt• 23.0 ft• RED/ORANGE CLAY
59.Well Location: 23.0 rt' 35.0 n' TAN SILTY CLAY
COPES - VULCAN f. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft
601 WEST SUMMIT AVENUE CHARLOTTE 28203 ft. ft.
Physical Address,City,and Zip
rt. rt
MECKLENBURG 21.REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-21.0-23.0 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 02/21/23
6.Is(are)the well(s): ITPermanent or ❑Temporary Signature ofCertified Well Contractor Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a copy
lfthis 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 421 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: 35.0 (ft.)
For multiple wells list all depths ifdierent(example-3(200'and Zen 100') Submit this GW-1 within 30 days of well completion per the following:
10. 30.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
fwa[er level is above easing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
/f
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 heat department o t e county w ere InstaTJ
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100 000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh, C 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection tvpe: Amount:
arm c North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018