GW1--07772_Well Construction - GW1_20231201

• .- - •WELL CONSTRUCTION RECORD
For Internal Use ONLY:.
. 'This'form can be Used for single or multiple wells' " ..
' 1.Well Contractor Information:
KEN"NY SARGENT- • •
.: 1A.WATERZONEs.:
FROM TO .DESCRIPTION
Well Contractor Naive ft.' ft
.. '. A _ 4226 . . .. , ' ft. ._ fc: : . 1 : ' -
NC Well Contractor Certification Number • . . .15:OUTER CASING(for multi=cased wells)ORLINER(if ap 7icable) ` • •
. - • FROM. . .TO - . DIAMETER • -THICKNESS MATERIAL . .
:GEOLOGIC.EXPLORATION. - : : - ft. . .ft: • I an: • - ' . "
Company Name ' . ., .. • 16.INNER-CASING OR TUBING(geothermal closed-loop) --
•70001364/V11M0301318' FROM • TO .. . DIAMETER THICKNESS .. •MATERIAL .. .
.2:Well Construction Pernut#; ft. ft. in. . .
'List all applicable well construction permits"(i.e.County,State,Variance,etc.) • : - ' ' -
tt.:
.3.Well Use(cheek well use)::•- : 17:SCREEN w.
Water Supply Well:• . • . . . .. . ' . . ,FROM' .TO . . • DIAMETER ' SLOT SIZE. THICKNESS. 'MATERIAL. •
❑Agricultural . : ❑Municipal/Pulilic
ft. fL. in.
' • '❑Geothermal(HeatinS/Cooling Supply) ❑Residential Water Supply{sin le) . . . •: ft ft• . - . -
Olndustrial/Commercial OResidential Water Supply(shared);
18 GROUT" .
.FROM - TO MATERIAL - EMPLACEMENT METHOD&AMOUNT
❑Irrigation ... . . ft, . . it . .. .
. . "Non-Water Supply Wellt . : • • .' . . • -.. r • :
ft. t
©Monitoring ORecovery.
Injection Wells it.• ft
' DAquifer Recharge '• : : ,❑Groundwater Remediation.- 19.SAND/GRAVEL PACK(if applicable) - ' ' • ' . . . '-
. ' . .FROM • TO . . - MATERIAL . . EMPLACEMENT METHOD "
' •• _ ❑Aquifer.Storage and Recovery' ' " .❑SalinityBarrier'
❑Aquifer Test • • . : • ❑Stonnwater Drainage • : •' .. : '
ft.• ft.. . .
❑Experimental Technology • 0Subsidence Control. - .' • • • • •.
• •20:DRILLING LOG(attach additional sheets if.necessary) . •-
: :❑Geothermal(Closed Loop) • : ', :❑Tracer : ; • FROM. TO • ',.DESCRIPTION(color:hardness,soil/rock type,grain elze,eta) •• •
• OGeotherm-al(Hee.ting/CoolingReturn) ' 'OOther.(explain Under#21-Remarks): 0:0 II'' : 1.0 'ft - GRASS/GRAVEL • .. .•. • ' '
10/1.7/23:- VAP.-3: • : ..1.0. ft.: 1 .0 , ra ' - . ', .': BROWN CLAY .. : .
: : • .4:Date Well(s)Completed: Well ID#
.. 15:0. f, • : ' ft
. . . . 46 0 BROWN SILTY;CLAY. : '
.: 5a:Well Location: •: 0 0 ft
U NIVAR 46. n 65. GRAY,SILTY-PDX'L
f,:: :i. .:l..
•
•
' ' ' . Facility/Owner Nacre : ' ' • • ' ,. Facility.ID#.(if applicable) '. . .. .
.5010 HOVIS ROAD CHARLOTTE _28208' • ft. ft.
. - • PhysicalA'ddress,City,.andZip'• ' • ' ' " 21:REMARKS : - il?l ;sG:=;'.^ii=' ''•''�4'.::''=a lyJ{ Y'- :
. • MECKLENBURG.: • : : •:WATER:SAMPLING THROUGH INFLATABLE PACKERSINSIDE'''Si7NIC'TOOLING •
'County: : • Parcel Identification No.(PIN)- • • .
' Sb;Latitude and Longitude in:degrees/minutes/seconds or decimal degrees: ' 22,Certification: .
(if well field,one lit/long is sufficient) ' . •• '
. . .
' 35o 16i Q7.67cc N 80o 53' 53.27.ic w, , _ , . ditil , . . 10/20/23
. Signature of Certified Well Contractor Date
6.Is(are)the.weil(s): [7Permanent• or." Temporary. .By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
• • "with'15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a •
' .7:Is This a repair to an existing well: ' ❑Yes. or ]No :copy of this record has been provided to the well owner. • - '•
If this is a repair,fill out known well construction information and explain the nature of the • • • .• ' . • I, ...• . • •
repair under#21 remarks section or on the back of this form. : •23,Site diagram or additional well details: .
' •You may use the back•of this page to provide additional well site details•or well" •
8:Number of wells constructed: . . •' . ' .. • construction details. You may also attach additional pages if necessary.. . •• •
. For multiple injection or non-water supply wells ONLY with the same construction,you can . ' . . - . . . .
submit one form.: •• '' SUBMITTAL INSTUCTIONS •
• 20.0/25.0/35:0/50.0/60:0 •. 9.Total well depth below land surface: (ft.) :24a. For All Wells: Submit this form within 30 days'of completion of well . .
.'. For multiple wells list all depths if different(example-3@200'and 2@100) - ' construction to the following: ,
- 10.Static water-level below top of casing: •25.0• • - (ft.) • • Division of Water Quality,Information.Processing Unit, • .
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC:27699-1617
• 11:Borehole diameter: 6'0 (in:) 24b.For Injection Wells:-In addition to sending the form to the address in 24a. '
• above, also submit a copy of this form within 30 days of completion.of well
- 12.Well construction-Method:-- SONIC .. . construction to the following: . r ' • . ;
(i.e.auger,rotary,cable,direct push,etc.) 1 .. '
. . . • • . . . Division of Water Quality,Underground Injection Control Program, .
. : , FOR WATER SUPPLY WELLS ONLY: •• . 1636 Mail Service Center,Raleigh,NC 27699-1636
• 24c.For Water SuDDly&Injectoon'Wells:•In addition to sending the form to
13a.Yield(gpm) Method of test: _ the address(es) above, also submit one copy of_this form within 30 days of. •
13b..Disinfection type:• Amount: co mpletion of well construction to the county health department of the county.
- where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water'Quality Revised Jan.2013
• •