GW1-2021-00830_Well Construction - GW1_20210215

WELL CONSTRUCTION RECORD rorhnemal llsc ON 1,
This fun,can be used fit,single or nml,ple,cells
I.%N ell Contractor Information:
Michael T. Stanforth, P.E. 14.WATER ZONES
FROM 1'O FESCRIPTION
well Contractor Name 13 n. 2l ft.
2525 ft.
NC Nell Contractor Cercificmimh Number 15.OUTER CASING for multi-eased wells OR LINER(if. fieable
FROM TO DLi\IL'rER OUCKNE5S NI ATERIAL
Excel Civil & Environmental Associates, PLLC ft. in.
Contpanp Narrtc 16.INNER CASING ORTUTNG eorstrmalekned-loop
A/\o^ ^�/ �l 1 I, FRO\I TO DIAM EI'F.R TIIICK\'ESS MATERIAL
2.NN ell Construction Permit 4: l�J�/l_./ "�/,� ^�l]r. 0 re 10 rr, 2 in. PVC
/.nh nl/npphenh/e tie//perru¢.2e C-mur1,..1'rure. I'ariance,/rgratnu.em/
t
3.\Fell Ise(check well use): 17.SCREEN
W"ater Supply Well: 11:O)1 TO DIAMETER SLOI'SIZE TIO('KNESS >I,NTERIAi.
❑Agricultural ❑Municipal/Public 10 R 25 fL 2 to 0.10 PVC
❑Geothermal(I leating/Cooling Suppl,,) ❑Residential Water Supply(single) R. I ft. t
❑Industrial/Commcrcial ❑Residential N'ater Supply(shared) 18.GROUT
FROM TO NIArERIAL ENIPLACEMENTNIETDOD&AMOUNT
❑Irrigation 1 f. 6 ft cement
Non-W'aler Supply Kell:
OMonitoring ❑Recover 6 D. $ If. bentonite
Injection Well: G. ft.
❑Ayuiter Recharge ❑GiOUnd,aler Remediation 19.SAND/GRAVEL PACK ifs rf:R !livable
ENIPLAClMEWNIET'110D
FRONT TO M.A
❑Aquifer Storage and Keco%cn ❑Saliniq'Barrier
8 f' 25❑Aquifer rest ❑Slormvsuter Orainnec ° medium quartz
❑Fsperimemal Technolog% ❑Subs'idence Control ft.
20.DRILLING LOG attach additional sheets if necessaryi
❑GIUlhenlla (Closed Loop) ❑Tracer FROM 'eD DESCRIPTION aoloc hardness,solVrockn e, e,etel
❑Geothermal(Ilcating Cooling Retum) ❑Other(explain under 421 Remarks) 0 ft. 1 ft. asphalt/gravel
J.Date Well(s)Completed: Well IDtt
1/25/21 MW-1 1 ft 6 fL reddish brown clay fill material
6 f'' 25 fL red sandy clay
5a.W'ell Location: tt ft
Estate of David Winfield Allen ft ft
Facilitc O,ner Name Facibn 1n'IifapplicableI
(t. ft.
1824 N Graham St., Charlotte, 28206 rt
Ph,sical Address,City.and Zip 21.REMARKS
Mecklenburg 07910202
Count, Parcel Identification No tPIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
to well field,one Io A.,is wfficiznt1
35.245337 N 80.831057 1/26/2021.
Signature of Certified Well Conuacmr Dale
6.Is(are)the well(s): ©Permanem or El emporan _ Hr.ol,r p tl is Iran, [herchr cern0 rl n rh.•rr((ryl nn. Nee)c,r,rrur red rn nccorAance
soh h 4 V(AC 02C 0100o,15A V Ar 021 0200 W/I( mnnsuan Smnddrds and rhos
7 is this a repair to an existing will ❑}es or 17)N0 2o'10OM lr/ onrd lm9h r n'idedr r/_ ell nv nee.
/(rl fill ow k 11 v r ....fa r rode,rla �dlnn e5r/. f-
r P<rnn.Ccr-21 r .W,sear:,n m th,book ollhr,form { DD 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number ofwells constructed: 1 construction details. You ma3'also attach additional pages ifnecessan_'.
For"Id',/,rrjecdon or non-r'mer nyrplr 11r11s ONI,Y that the X4ce f'o'resrNeMn.vnn tun
,uhnm one f.,n SUBNI IF TAL INS TUCTIONS
9.Total well depth below land surface: 25 (fq 24a. For All Wells: Submit this lixm within 30 dues of completion of well
For mubhpleiedloD.0 till deprh.n/d,11e,,,r(ezample-3tt200 ,el24Z100') constnlctlontothefollowinu,
10,Static hater level below lop of casing: 13 (ft.) Division of Water Resources,Information Processing I'nit,
I/ mer(ere[rs ah,mu cosirhg.tics, 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ON LA ID addition to sending the Ibnn to the address in
24a above. also submit a cop} of this form within 30 days of completion of well
12.W'ell construction method: auger construction to the hollowing-
0 e.auger rotary,cable,direct porch.em u
Division of Water Resources,I'nderground Injection Control Program,
FOR WATER SUPPLA'WELLS ONLI: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.A'ield(gpnq— _ _ Method of lest
24c.For Water Supplv&Infection Wells:
Also submit one cop% of this form within 30 da%sofcompletion of
13b.Disinfection type:__ _ Amount: \,ell cons'Iruction to the count\' health department of the count%where
constructed
Fovn Gll'-1 NonhCaoil,ii,iDpartment(it En, roonient and Natural ltesoolces—Division ofWater lteroumcs Rev ised August 2011