GW1--03029_Well Construction - GW1_20230310

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Firas Mishu 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
35 ft• 37
4461-A , I
NC Well Contractor Certification Number 15.OUTER CASING for mold-cased wells OR LINER if a licable
M&W Drilling, LLC FROM ft. TO ft. DIAMETER to. TIIICICNESS MATERIAL.
Company Name 16.INNER CASING OR TUBING thermal closed-loop)
70003120
2.Well Construction Permit#: FROM TO DIAMETER T ICKNESS MATERIAL
List all applicable well construction permits(1.e.ff1C,County,State,Variance,etc.) 0 ft- 27 ft- 2 1O sch 40 PVC
3.Well Use(check well use): ft. ft. I In.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 27 ft- 37 ft' 2 in. 10 sch 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft, in.
IndustriaUCommercial Residential Water Supply(shared) la,GROUT
-11rrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft' None
Monitoring []Recovery
Injection Well:
Aquifer Recharge []Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERIAI. EMPLACEMENT METHOD
Aquifer Test []StormwaterDrainage 20 f`• 37 ft- #2 Filter Sand Tremie
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiVrock type. rain size.etc.)
Geothermal(Heating/Cooling Conlin Return) Other(explain under#21 Remarks) -
0 ft• 18 ft• Brown.Soil
4.Date Well(s)Completed.. Well>D#TMw-� 18 f` 37 f` Gra t_Rock
ft. ft.
5a.Well Location: -
Johnson &Wales University
Facility/Owner Name Facility ID#(if applicable) -
713 W. Trade St., Charlotte, NC 28202 ft. ft.
Physical Address,City,and Zip
Mecklenburg 21.REMARKS -
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.unc ladlong is sufficient) 22.Certification:
35.231943 N -80.848922 W it 3 1-13
6.b(arc)the well(s)13Permanent or 211'emporary Signature of Certified Well Contractor fate
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or Jallo with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fit out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells constriction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 37 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d8erent(example-3 r@200'and 2@100') construction to the following:
10.Static water level below top of easing:19.25 (ft.) 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: 5-5/8 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Air Rota above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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 SuuDly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016