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Home My WebLink AboutGW1-2022-07516_Well Construction - GW1_20220811 r WELL CONSTRUCTION RECORD For Internal Use ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: �j Y y i 5 N"ED :14.�WATERZONES Bill J. Payne Jr. FROM TO DESCRIPTION Well Contractor Name A U G ! y 2022 12.33 t` 22 ft Non-Potable Water 4532-B ft. ft. InfOf pr1atiDn PrµL q Und FROMUTER CASING for m DIt IAMEed TE ells OR LINER if a` 'ticable NC Well Contractor Certification Number rJtatG/$00 R THICKNESS . MATERIAL Excel Civil & Environmental Associates, PLLC o ft 12 fL 2 in. 1 0.154" PVC Company Name 16.INNER CASING OR TUBING eothermal closed-loop) "mh 70002951 FROM TO DIAMETER THICKNESS MATERIAL 2.Well Construction Permit#: fL ft. in. List all applicable well permits(i.e.County,Stale,Variance,injection,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 12 It. 22 It. 2 in. 0.10 0.154" Sch 40 PVC ❑Geothermal. eatin Coolin Supply) ❑Residential Water Supply(single) ft. fL in. (H.... S/ g PP Y) PP Y( g ) ❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT ' .FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT ❑Irri ation 0 fL 8 ft. Neat Cement Tremie Pipe Flow/80 lb Non-Water Supply Well: .. 8 f` 10 ft- Bentonite 3/8' Tremie Pipe Flow/15 lb OMonitoring- ❑Recovery Injection Well: 10 " . 22 f` #2 Sil.Sand. Consolidation Method/40 lb ❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVE L PACK;if a' licable . FROM TOMATERIAL EMPLACEMENT METHOD ❑Aquifer Storage and Recovery ❑Salinity Barrier 12 fL 22 ft #2 Sil.Sand 20-28 Consolidation Method ❑Aquifer Test OStormwater Drainage tt. tt. ❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach'additional sheets if necessary) ❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc. ❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 1 fL 2"Topsoil-Brn Red Sandy SILT, 4.Date Well(s)Completed: Well ID# 08-5-2022 MW-4 1 fL 6 fL Brn-Red Sandy SILT(Dry) 7 ft, 10 ft. Lt Bm SILT(PWR) 5a.Well Location: 11 ft 12 ft. Grey Sandy Clay SILT(Mica)(Wet) Sam's Mart No. 74 00-0-0000035588 Inc#48068 13 fL 18 ft. Grey Lt Brn Sandy Clayey SILT(Wet) Facility/Owner Name Facility ID#(if applicable) 9810 UniversityCity Blvd, Charlotte, 28213 19 ft. 22 ft. Grey Brn Clayey SILT(Saprolite Clay) Y 22 ft. 22 fL Refusal due to PWR/possible Bed-Rock Physical Address,City,and Zip 21:REMARKS' . Mecklenburg County 5112105 0 to 12-ft 2"Sch 40 PVC Flush Environmental casing County Parcel Identification No.(PIN) 12 to 22-ft 2"Sch 0 PVC 0. 10"slotted screen w/Molded cap 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2.C fication: (if well field,one lat/long is sufficient) 35.18 29.63 N -80. 43 10.84 W 8-9-2022 Signaturl of Certified Weh ContractA Date 6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with 15A 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 ofthis record has been provided to the well owner. 1f this 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: 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. SUBMITTAL INSTUCTIONS 9.Total well depth below land surface: 22 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: 12.33 tft) Division of Water Resources,Information Processing Unit, ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 11.Borehole diameter: 4.25" O/2" 1 (in) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in 4.25" auger-method 24a 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 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 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 PROJECT: SM74 8"-0 X 12"-D STEEL WELL ID. NO. 9810 UNI VERSI TY Cl TY BLIND MANHOLE W/ MIN 18" X 18" CHARLOTTE, N.C. CONCRETE PAD MW-4 WELL PERMIT # 70002951 (PAD WILL BE SLOPED TO MATCH NCWC # 4532-B EXISTING GRADE SLOPE) GRADE 0' 2" PVC CASING 12' 8GL 0' - - - - - - - - - - - - - - - - - - - V& V& WELL SEAL NEAT CEMENT 8'-10' 8GL - - - CONCRETE - - - - - - -NO, SAND PACK 10' - 22' BGL - - - - - - - - - - - BENTONITE HOLE PLUG 2" PVC SCREEN NIN 12' - 22' BGL - - - - - - - - - - ---------- UNDISTURBED EARTH N111% #2 SILICA SAND 20-28 SLOT GRAVEL PACK (IF APPLICABLE) ANN, TOTAL DEPTH 22' BGL -- - - - - - - - - - - - TYPE 11 MONITORING WELL CONSTRUCTION DETAIL (TYPICAL - N.T.S.) F:NC/PROJECTS/WELL INSTALL/SM74/MW4-CONSTDTL-8/9/22