GW1-2021-05381_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This•form can be used for single Or multiple wells
1.Well Contractor Information:
Jay Little G 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name .
p11
27/7 -A ( tt ft. it
NC Well Contractor Certification Number O�` �y U 15.OUTER CASING for multi cared wells OR LINER d a licable
S&M E Inc. C ��vr�, J FROM TO DIAMETER THICKNESS MATERIAL.
1 �'.�'111 crti:Ofi
ft. ft. in.
Company Name ��2�'1�jrs 16.INNER CASING OR TUBING eothermat closed-loop
7 0 v FROM TO DIAMETER THICKNESS MATERIAL,
0
2.Well Construction Permit#: 8' ft. ft in•
List all applicable well construction permits(i.e.County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaVPublic 10 ft. )S ft. Z in C)'1 d ct H Y@ PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18 GROUT ;
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation ft. ft. -
Non-Water Supply Well:
Monitoring ❑Recovery ft. ft. 6y,. 1}103 PUtr 2
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑A uifer Storage and Recovery ❑Salim Barrier FROM TO MATERIAL EMPLACEMENT METHOD
4 g ry ty Ir ft. ls" ft. �Z s/•}Ni' i/f�-+^+,R%t
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soWrock typc n size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) � ft. D ft. ^rF4ft//�. 01 Nse 7a Lwie CZA-'e'r
tt. ft S�}NQ frnt_t,MP-..r)cv^ti
4.Date Well(s)Completed: 0 u%1�L
ft. ft. A60 f fw_161
5.Well Location: 87 Charlotte-Mecklenburg Board of Education ft. ft zy�� - s=L y
ft.
Facility/Owner Name Facility ID#(if applicable)
7601 The Plaza ft. ft `0 ,� '�,
ft. ft
Physical Address,City,and Zip 21.REMARKS
Mecklenburg 10509129 Piezometer identified as PZ-1
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)
35.260485 N -80.732800 W
Sign of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or [2Temporary By signing this form,1 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 0No copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
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 ONLYwith the same construction,you can
submit one form. 24.Submittal Instructions:
9.Total well depth below land surface: 15 (ft.) 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@I001 construction to the following:
10.Static water level below top of casing: NO+ rnJd> hexed (ft.) Division of Water Quality,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Auger 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 Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Geothermal 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 Environment and Natural Resources-Division of Water Quality Revised Jan.2013