GW1-2022-07527_Well Construction - GW1_20220811

IN
WELI CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14 WATER ZONES
Bryan Vest .
FROM TO DESCRIPTION
Well Contractor Name 19 ff 35 ft
3580-A fL ft.
NC Well Contractor Certification Number .15.OUTER CASING for molti-Cased wells OR LINER it a` "licalile" -
FROM TO DIAMETER THICKNESSI MATERIAL
Ransier Environmental Drilling, INC. (REDI) 0 ft 120 rL 15 in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)m
70002951 FROM TO IDIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: °"�'tf°j 0 ft. 30 ft. 2 in. SCH 40 PVC
List all applicable well permits(i.e.County,State, Variance,bJ)�?&'j@n,
ft. ft. in.
3.Well Use(check well use): AUG 1 1 2022 17.SCREEN. .
Water Supply Well: FROM TO DIAMETER ,SLOT SIZE _THICKNESS MATERIAL
❑Agricultural ❑Mttl�tf�2 Prs'„ ftJ U 30 ft 35 ft 2 `"' 0.010 SCH 40 PVC
M"i,Jo/80G ft. fL in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT.
❑lrri ation 0.5 ft. 26 fL Cement pour
Non-Water Supply Well:
RI 26 ft- 28 ft- Bentonite pour
Monitoring.. ..... ❑Recovery
Injection Well: FL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a 011cible
FROM TO MATERIAL EMPLACEMENT METHOD -
❑Aquifer Storage and Recovery ❑Salinity Barrier 30 ft 35 ff #3 gravel pour
❑Aquifer Test ❑Stormwater Drainage
fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach'ddditional sheets if necess"s'c
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL 1 ft. Asphalt/Gravel mix
4.Date Well(s)Completed: Well ID#
6/30/2022 VW_1 1 It. 18 ft. Lt. Brn(Tan)Silty CLAY
18 ft. 33 fL Lt. Brown Weathered Rock
5a.Well Location: 33 ft. 35 IL Rock
(former) Sam's Mart 74 ft. fL
Facility/Owner Name Facility to#(ifapplicable)
ft. ft.
9810 University City Blvd, Charlotte, 28213 ft. ft.
Physical Address,City,and Zip
21.REMARKS
Mecklenburg 05112105 Fnished with flush mount cover
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)
35.18 29.63 N 81.918747 W 14e, 8/9/2022
Signatu of Certified Well Contractor 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 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 35 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 19 Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 Outer/5 inner (in) 24b. For Injection 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/Ali hammer 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-I 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 CITY BL VD
MANHOLE W/ MIN 18" X 18" CHA RL 0 TTE, N.C.
CONCRETE PAD VEW- 1 WELL PERMIT # 70002951
(PAD WILL BE SLOPED TO MATCH NCWC # J580-A
EXISTING GRADE SLOPE)
GRADE 0'
......... ...
2" PVC INNER CASING
0' JO' BGL
-- - - - - - - - -I-
NIR
NEAT CEMENT
CONCRETE zt: WELL SEAL
0.5'-26'
- - - - - - - - - - -
8" OUTER BORING
ANNULUS
Y8" BENTONITE
HOLE PLUG 26'-28. WATER TABLE
19' BGL
- - - - - - - - - - - - - -
5" OUTER CASING/RISER
UNDISTURBED EARTH
5" OUTER RISER/CASING
AN- % -% 0'-20' BGL
#2 SILICA SAND 2" INNER SCH 40 RISER/CASING
20-28 SLOT 0'-JO' BGL
2" SCH 40 PVC SCREEN
PREPACK/ - - - - - -JO' - J5' BGL
#3GRAVEL PACK 3%lN SAND PACK
(IF APPLICABLE)
NIN TOTAL DEPTH
Big - - - - - - - -J5' BGL
0.51 ASPHALT
4-
o.5' GRAVEL
18, LT. BRN (TAN) TYPE III MONITORING
SILTY CLAY WELL CONSTRUCTION DETAIL
(TYPICAL N.T.S.)
33, LT. BRN WEATHERED ROCK
'lop,
35' LT. BRN WEATHERED ROCK
F:NC/PROJECTS/WELL INSTALL/SM74/VEW-1-CONSTDTL-6.30.2022