GW1-2022-07102_Well Construction - GW1_20220801

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy J. Payne Jr. pllr, 1 �_ 2022 `FRO ATERZTO ONES `DESCRIPTION
Well Contractor Name 3 It 24 fL Non-Potable Water
t►f
4532-B l�yflsat D% Prat fL fL
Q/t304 15.'OUTER CASING for multi cased
NC Well Contractor Certification Number wells OR LINER`if,a lica'AT ,
FROM TO DIAMETER THICKNESS MATERIAL
Excel Civil & Environmental Associates, PLLC , 0 ft- 14 fL 2 in. 0.154" 1 PVC
Company Name 16.INNER CASING OR TUBING eoihermal closed-loop)
70002951 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft: in.
List all applicable well permits(i.e.County,State,Variance,Ir jection,etc)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 14 IL 24 fL 2 in. 0.10 0.154" Sch 40 PVC
❑Geothermal(Heating/Cooling Coolin Supply) ❑Residential Water Supply fL fL in.
M g/ g pp y) pp y(single)
1F8RO TO GROUT
❑IndustriaUCommercial ❑ROSldentlal Water Supply(Shared) MATERIAL_ EMPLACEMENT METHOD&AMOUNT
Non-Waate
❑ ter Supply Well: p fL 12 ft- Neat Cement Tremie Pipe Flow/80 lb
oMonitoring ❑Recovery 10 rL 12 fL Bentonite 3/8' Tremie Pipe Flow/15 lb
Injection Well: 12 1` 24 ft- #2 Sil. Sand , Consolidation Method/40 Ib
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a 'licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 12 It- 24 ft #2 SII.Sand 20728 Consolidation Method
❑Aquifer Test ❑Stormwater Drainage
fL fL
❑Experimental Technology ❑Subsidence Control
'=20.DRILLING LOG attach'idditional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiUrock type,gnin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J 0 fL 1 ft. 2"Topsoil-Brn Red Sandy SILT
07-25-2022 MW-3 1 fL 6 fL Brn-Red Grey Sandy SILT(Dry)
4,Date Well(s)Completed: Well iD#
7 IL 10 ft. Brn Silty Clay w/Sand
5a.Well Location: 11 ft 12 fL Grey Sandy Clay(Mica)
Sam's Mart No. 74 00-0-00000355881nc#48068
13 rL 22 fL Grey Lt Brn Sandy CLAY(Moist)
Facility/Owner Name Facility ID#(if applicable)
28213 23 rL 24 rt• Grey Brn Sandy Clay(Saprolite Clay)
9810 University City Blvd, Charlotte, 24 fL 24 fL Refusal due to PWR/possible Bed-Rock
Physical Address,City,and Zip 21.REMARKS
Mecklenburg County 5112105 0 to 14-ft 2"Sch 40 PVC Flush Environmental casing
County Parcel Identification No.(PIN) 14 to 24-ft 2"Sch 40 C j0.10"slotted screen w/Molded cap
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Ce lion:c
35.18 29.63 N -80. 43 10.84 W 7-27-2022
S nature of Certif d elf ntractor Date
6.Is(are)the well(s):-©Permanent or ❑Temporary 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.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E]No copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis jorm. 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 24 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths itdifferent(example-3 200'and 2@100) construction to the following:
10.Static water level below top of casing: 13.33 (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: 4.25" O/2" 1 (in) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
4.25" auger-method er-method 24a 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 Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: 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,Resources Revised August 2013
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PROJECT: SM74
8"-0 X 12"-D STEEL WELL ID. NO. 98'10 UNIVERSITY CITY BLVD
MANHOLE W/ MIN 18" X 18" CHARLOTTE, N.C.
CONCRETE PAD MW--3 WELL PERMIT # 70002951
(PAD WILL BE SLOPED TO MATCH NCWC # 4532-B
EXISTING GRADE SLOPE)
GRADE - 0'
2" PVC CASING
0' - 14' BGL
ISM
- - - - - - - - - - - - - - - - - -
WELL SEAL
NEAT CEMENT 10'-12' BGL
/ CONCRETE - - - - - - - - - - - - - - -
SAND PACK
12' - 24' BGL
38" BENTONITE
HOLE PLUG 2" PVC SCREEN
NIN
14' - 24' BGL
UNDISTURBED EARTH
#2 SILICA SAND
20-28 SLOT -
GRAVEL PACK
(IF APPLICABLE) `
TOTAL DEPTH
L
- 24' BGL
N...
",
N nkw
TYPE II MONITORING
WELL CONSTRUCTION DETAIL
(TYPICAL - N.T.S.)
F:NC/PROJECTS%WELL INSTALL/SM74/MW3CONSTDTL_7.27.22