GW1--01249_Well Construction - GW1_20240229

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RESIDENTIAL WELL CONSTRUCTIONS RECORD
--4.4z-v NON` o North Carolina Department of Environment and Natural Resources-Division of Water Quality
.. ,' WELL CONTRACTOR CERTIFICATION# 2717-A ,
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1.WELL CONTRACTOR: d. TOP OF CASING IS N/A, FT.Above Land Surface*
Jay Little *Top of casing terminated.at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118.
Well Contractor(Individual)Name
S&ME, Inc. e. YIELD(gpm): N/A METHOD OF TEST N/A
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Well Contractor Company Name f. DISINFECTION:Typei'N/A Amount N/A
STREET ADDRESS 2016 Ayrsley Town Blvd, Suite 2A g. WATER ZONES(depth):
From N/A To N/A From N/A. To N/A
Charlotte NC 28273 N/A N/A; N/A N/A
City or Town State Zip Code From To FromTo
(704 )_ 523-4726 From N/A To N/A, From N/A To N/A
Area code- Phone number 6. CASING: Thickness/
2.WELL INFORMATION: From 0 DeTpth
87 I Ft.2-in.
DiameterSce.1q �V(;
�llatgrial
_ SITE WELL ID#(if applicable) ITZ-27
, - - ` STATE WELLPERMIT#(if app-Eitile)N/A `----- --From N/A__To-N/A _L Ft.N/A _ _ _._N/A N/A _
From N/A To N/A I Ft. N/A N/A N/A
DWQ or OTHER PERMIT#(if applicable) SIP 70001078 i
WELL USE(Check Applicable Box)Monitoring 0 Municipal/Public 0 7. GROUT: Depth Material Method
From 0 To 84 Ft. Neat Cement Pour
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection❑ From 84 To 86.4 Ft. Bentonite Pour
Irrigation❑ Other tg (list use) Air Sparging
From 86.4 To 86.7 'Ft. k-packer N/A
DATE DRILLED 1/15/2024
8. SCREEN: Depth ' Diameter Slot Size Material
TIME COMPLETED afternoon . AM 0 PM in 87 92 2 0.010 PVC
From To Ft. in. in.
3.WELL LOCATION: From N/A To N/A 'Ft.N/A in. N/A in. N/A
CITY: Charlotte COUNTY Mecklenburg From N/A To N/A Ft.N/A in. N/A in. N/A
Mount Holly Road(MCK Terminal) 9. SAND/GRAVEL PACK:
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Depth Size Material
TOPOGRAPHIC/LAND SETTING: From 92 To 96 Ft. #2 filter sand
❑Slope 0 Valley ®Flat 0 Ridge 0 Other From N/A To N/A Ft. N/A N/A
(check appropriate box)
35.2808 May be in degrees, From N/A To N/A 1 Ft, N/A N/A
LATITUDE
-80.9436 minutes,seconds or 10.DRILLING LOG
LONGITUDE in a decimal format From To Formation Description
Latitude/longitude source: ]81GPS ❑Topographic map 0 35 Silty Sand
(location of well must be shown on a USGS topo map and 35 96 granodiorite
attached to this form if not using GPS)
4.FACILITY-Is the name of the business where the well is located.
FACILITY ID#(if applicable) N/A [' --
- __ NAME OF_FACILITY MCK Terminals, LLC(MHRG) _ e -� V-1 P I�li�"`'
STREET ADDRESS 8035 Mt. Holly Road FEB 2 0 2024
Charlotte NC 28214
City or Town State Zip Code , ITt#Orrraar n ?r:v:..'✓'.f vt:a tint
CONTACT PERSON Scott Janashak "ViCt'
MAILING ADDRESS 1100 SitUS Court, Suite 100
Raleigh NC 27606 11.REMARKS:
City or Town State Zip Code Sparge well is direct buried. Water level is approximately 5 feet
( 904 )_ 571-2011 bls. - -
Area code- Phone number
5.WELL DETAILS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: 92 feet RECORD HAS B N PROVIDED TO THE WELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO lid / I 1-% t' 2—iD Ey
SI I A,/ RE OF CERTIFIED C WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: N/A FT. Jay Little
(Use"+"if Above Top of Casing)
PRINTED NAME OF PERSON,CONSTRUCTING THE WELL
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Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-lb
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. Rev.7/05