GW1-2021-02696_Well Construction - GW1_20210615

WELL CONSTRUCTION RECORD €'' For Internal Use ONLY:
This form can be used for single or multiple wells �� �.
1.Well Contractor Information: Q
Billy J. Payne Jr. >, {.O� ,` FR MATERZONES TO DESCRIPTION
Well Contractor Name ptnG �5�n'v 7 fc. 14 rL non-potable water
� 6
4532-B
NC Well Contractor Certification Number '' ®v 15.OUTER CASING for multi-eased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Excel Civil & Environmental Associates, PLLC 0 ft. 4 ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM
2.Well Construction Permit#: 70002813 ft TO ft. DIAMETER THICKNESS MATERIAL
in
List all applicable well permits(i.e.County,State, Variance.Injection,etc.)
ft. ft. j in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 4 ft- 14 fL 2 in. 0.10 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 rt. 2 fL bentonite:/cerr
Non-Water Supply Well:
OMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
2 ft' 14 ft. sand
❑Aquifer Test ❑Storrnwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type in sire etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 ft. 1 rn asphalt/gravel
4.Date Well(s)Completed: 5-10-2021 Well ID# MW-1 1 ft. 8 ft. tan silty clay
8 ft• 14 ra brown sandy clay
5a.Well Location: tt. ft.
(former) Sam's Mart No. 80 00-0-0000035683 ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft
8325 Old Statesville Rd, Charlotte, 28269
ft. ft.
Physical Address,City,and Zip
21,REMARKS
Mecklenburg 03725316 0-4-ft casing
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2 ertificatio
(if well field,one IaUlong is sufficient)
35.335972 N -80.825430 r.,` 6-8-2021
S f Certifi d Well Con ctor 1 Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that:the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair tinder#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: 1 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 14 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: 7 A) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 4 (in.) 24b.For Infection Wells ONLY: 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: auger construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this forme within 30 days of completion of
13b.Disinfection type: Amount: 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 Resources Revised August 2013