GW1--03028_Well Construction - GW1_20230310

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
A - 3098 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
rt. 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.UIC,County,State,Variance,etc.) 0.0 ft- 25.0 ft- 2.0 1n. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25.0 B' 35.0 fL 2.0 1n. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 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. 21.0 It' PORTIANDBENTONITE SLURRY
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge 15Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 23.0 f- 35.0 fL 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#21 Remarks) FROM TO DESCRIPTION color,hardness,soit/mck type,gmin size,etc.
0.0 ft. 15.0 ft- CONCRETE/BRICK BACKFILL
4.Date Well(s)Completed: �2�10/23 Well ID# IW-13-22A 15.0 ft. 23.0 fL RED/ORANGE CLAY
5a.Well Location:
23.0 ft- 35.0 B' TAN SILTY CLAY
COPES - VULCAN ft. ft. -
Facility/Owner Name Facility ID#(ifapplicable)
601 WEST SUMMIT AVENUE CHARLOTTE 28203 ft. 13.
Physical Address,City,and Zip ft. ft.
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:
(ifwell 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)' OPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wel/(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No 15A NCAC 02C.0I00 or/SA NCAC 02C.0100 Well Construction Standards and that a copy
tf lhis is a repair,fil/out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under 421 remarks section or on the back ofthis 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 hsi all depths ifdi,#erem(example-3@200'and 2 ct7r I00') 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),
Ifsvater 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 n-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department o e county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over 100,000 GPD:Copy to DWR,CCPCUA
(gPm)
13a.Yield Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection I)pe: Amount:
Porn,O\\-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018