GW1-2021-05395_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor information: yd
Jay Little ,� pi a• 144 MATERZONESFRO TO DESCRIPTION
Well Contractor Name ft. ft.
2 217 ^/P p C� 1 `ij 2021 ft. ft.
NC Well Contractor Certification Number r ry V 111�, 15.OUTER CASING for multi cased?wells OR LINER it a ticable
r !�`� FROM TO DIMIETER THICKNESS MATERIAL
S&ME, Inc. `�;��13^���SvCI,On ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
70002918 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: tt. ft. in.
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public S ft. I ft. Z in. w^ sL� 40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. ft.
Non-Water Supply Well: 3 1��At9J.ni5^�Fs PQ V r2
OMonitoring ❑Recovery ft. ft. GtfiPs
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK If applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑A uifer Storage and Recovery ❑Salim Barrier
❑Aquifer Test g ry ❑Stowater Drainage 3 ft. 10 ft. #Z S A IV -720rtfE
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionni sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,softtrock typc n size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. /VGA Av b&Z PN136'C -
4.Date Well ft. ft. /VU SA-&:EAl6s)Completed: $��Z�Z I
tt. tt.
5.Well Location:
Charlotte-Mecklenburg Board of Education
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
7601 The Plaza f`
ft. n
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 10509129 Piezweter identified as Pz-4
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.259497 N -80.732459 W
SignatupogrCcrtificd Well Contractor Date
6.Is(are)the well(s): ❑Permanent or 2Temporary By signing this form,1 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 BNo 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
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: 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 one form. 24.Submittal Instructions:
9.Total well depth below land surface: 10 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: AJ& E4L0'-^k r41 (ft.) Division of Water Quality,Information Processing Unit,
lfwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Auger above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Y
24c.For Water Supply&Geothermal 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
completion of well construction to!the county health department of the county
13b.Disinfection type: Amount: where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013