GW1-2022-03860_Well Construction - GW1_20220331

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
z, ,r This form can be used for single or multiple wells
1.Well Contractor Information:
s 14.WATER ZONES >
Billy J. Payne Jr. FROM TO UEscRtPTION
(l t Well Contractor Name 17.5 it- 24 it non-potable water
4532-B it. ft.
r r 15 OUTER CASING formulti-cesed'wells OR LINER tf a licable
NC Well Contractor Certification Number FROM TO. DIAMETER THICKNESS MATERIAL -
,� `+ Excel Civil & Environmental Associates, PLLC 0 It. 9 ft 2
t t 1 Company Name rm 16.INNER CASING OR TUBING eothe al closed-loop)
FROM TO DIAMETER THICKNESS FUTERIAL <
70002992
2.Well Construction Permit#: ft. fL in
'List all applicable well permits(i.e.Counry,State;Variance,Injection,etc.) ft. in.
3:Well Use(check well use): 17.SCREEN
FROM ME TO DIATER! SLOT SUE THICKNESS MATERIAL
a - Water Supply Well:
< r ' ! ❑A cultural ❑Munici al/Public 9 ft 24 fL 2 1° 0.10 PVC
x p ft. ft. in.
t l t []Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)'
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT .
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
4 w, +}r+ 01rri tion 0 ft. ft.
r� WNon- ater Supply Well:
6 bentonite/ce
! I .c ft. M
� s .'OMonitoring ❑Recovery
E/F 1o4 Y� Injection Well: fL ft
Fs, ❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK-if applicable)
b -
FROM TO MATERIAL EMPLACEMENT METHOD
}, ❑Aquifer Storage and Recovery ❑Salinity.Barrier ft ft
OAquifer Test OStormwater Drainage
9 24 Sand
1 ft. ft.
t I Technology❑Experimental Technolo ❑Subsidence Control
20.DRILLING LOG attach addition
r t •i' - '' al sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,ffain si etc.)
OGeothermal (Heating/Cooling Return ❑other(explain under 421 Remarks) 0 ft 1 ft asphalt/gravel-moist
r 1 - 1 r 't� 03/07/22 MW-2 2 (back fill)i` it• ( ,fill)gravely mix-semi-wet_(ODOR) _
E ! 4.Date Well(s)Completed: Well ID#
2 it, 10 ft- dk brown sandy-CLAY-semi-moist_(ODOR)
Ss.Well Location: 8 fL 14 fL dk brown Green silty CLAY-Smoist (ODOR)
I�ti+�l i'f,' (former)Sam's Mart No. 37 00-0-0000013957
14 ft19 it brown silty CLAY-Smoist_(ODOR)
,Eq 4"E Facility/Owner Name Facility ID#(if applicable)
•
t ' ` 2700 N Tryon St., Charlotte, 28206 19 24 brown silty CLAY-Smoist_(ODOR)
`` i 24 24 bedrock
77
('a{Y ,A Physical Address,City,and Zip 21.REMARKS
Mecklenburg 08302202 0-9-ft casing
0
r 9 -
County Parcel Idenfification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. Ica'on:
y to r. r (if well field,one lat/long is sufficient)
350 14' 56.21" -80°48' 54.28° 3-29-2021
k re N W
c}}
Signa ,fled WeII tractor 'I -Date,, T
6.1s(are)the well(s): OPermanent or ❑Temporary
By signing this form,I hereby certify!h'at'the wells)•coos(were)constructed In accordance
a4 with 15A NCAC 01C.0100 or I SA NC.&02C.0200 Well Construction Standards and that a
µ iat 7.Is this a"repair to an existing well: OYes or E]No copy of this record has been provided to the well owner. y
q- Ijthts is a repair,fill out known well construction information and explain the nature of the.
repair under#11 remarks section or on the back of this form. 23:Site diagram or additional well details: '
r 1 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 -
o v1
'' +' I 9•Total well depth below land surface: 24 (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 1@100) construction to the following:
17.5 Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: (ft.)'
�,� ;i• If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
.11.Borehole diameter. 4 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address
t pti°tr 24a above, also submit a copy of this form within 30 days of completion of weir'
d ;= .12.Well construction method: auger construction to the following:
R (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
li ,k' 13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form 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