GW1--03031_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 DESCRIPTIONtt. ft.
A - 3098 i:' - D. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION AA,�(( � y f� r) FROM TO DIAMETER THICKNESS MATERIAL
i'Vlnf\ �rl.� rt. rt. in.
Company Name
in;, _ ,�l ;:, 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#' FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC County,Rmte. l ariunce,erc.) 0.0 ft. 50.0 ft. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaUPublic 50.0 n- 60.0 ft. 2.0 to .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 I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 rt• 46.0 fit- PORTLANDBENTONITE SLURRY
❑Monitoring ❑Recovery
Injection Well:
❑Aquiter Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 48.0 rf• 60.0 ft. 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,soil/mIt type,Zmin sim,etc.
0.0 ft. 15.0 ft. CONCRETE/BRICK BACKFILL
4.Date Well(s)Completed: 02/08/23 Well ID# IW-13-24C 15.0 ff• 27.0 r' RED/ORANGE CLAY
5a.Well Location: 27.0 ft' 48.0 R TAN SILTY CLAY
COPES - VULCAN 48.0 n- 60.0 ft- TAN PWR
Facility/Owner Name Facility ID#(if applicable)
601 WEST SUMMIT AVENUE CHARLOTTE 28203 ft. tt
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:
(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): OPermanent or ❑Temporary Signature ofCenified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance with
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
Ifthis 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#11 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: 60.0 (ft)
For multiple wells list all depths if di//ereni(example-3@200'and 2@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),
lfwater 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 1 and O n-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county envlronmenta ealt department o the county where Installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over
13a.Yield(gpm) Method of test: 100 000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,N 276 9-1611
13b.Disinfection type: Amount:
Form GW-I North Carolina Department of Ew,ironmental Quality-Division of Water Resources Revised 6-6-2018