GW1-2021-05396_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 !�"1 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name n t 1 ft. ft.
ji i0 i 15.OUTER CASING for multi cased wells OR LINER if a licable
NC Well Contractor Certification Ift�T1 ^piPJ6��R01.0
S&M E, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
70002918 FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft ft in.
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft, ft. is
3.Well Use(check well use): .17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 110 It. KS ft. Z th• 10 " SC# yD i-VL
❑Geothermal(Heating/Cooling Supply) ❑Residential Water SuPP1Y(single) f. f. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 'r6 ft. (IIFN701V17f_ Pape
Non-Water Supply Well:
ft. fL t,l+rps
ZMonitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if.applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier #Z SA
ti i 2�i'ttE
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilfrock typc n size,Ma
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ". 1111A AuL62 O(Z4/136
ft. ft. N p�MPL1 NV
4.Date Well(s)Completed: Z/Z
5.Well Location:
Charlotte-Mecklenburg Board of Education
ft. ft.
Facility/Owner Name Facility ID#(if applicable)
7601 The Plaza R: ft.
Physical Address,City,and Zip 21 REMARKS
Mecklenburg 10509129 Piezometer identified as PZ-3
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)
35.259741 N -80.732980 W fit: -ice-z,
SignatgpKfCcrtified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or 12Temporary 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 BNo 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 ONLY with 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 ii dii ferent(example-3@200'arand 1@I00') construction to the following:
10.Static water level below top of casing: NO k 671[0-^krCt (ftJ Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
C[
11.Borehole diameter: V (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-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013