GW1-2023-01511_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: R c:Z �...5 �ey;
° 14.WATER`ZONES <..
Billy J. Payne Jr. -O FROM TO DESCRIPTION
Well Contractor Name 18 ft' 22 ft. Non-Potable Water
Inrii l^1 r� �r ft. ft.
4532-B r�-•�.: ;F�L'nif
NC Well Contractor Certification Number Jt1'e'QI�0G �1$:OUTER;CASING for multi casii';ivells ORLINER'if-a licable?e."
FROM TO DIAMETER THICKNESSr MATERIAL
Excel Civil & Environmental Associates, PLLC 0 ft. 17 ft' 12 i in- 1 0.154" 1 PVC
Company Name _16ANNER CASING ORTUBING` eothermal closed-loo
70002951 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. _ ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. rt. in.
3.Well Use(check well use): '-17.SCREEN-��`,`-;"
a
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaMblic 17 ft 22.5 ft. 12 in. 0.10 1 0.154" 1Sch40Pv0
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft it. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) =18.:GROUT:e� is 'x .r 'f'��••-;-.a. � ;,= ` '_
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑h-ri ation 0 rt. 5 It' Neat Cement Tremie Pipe Flow/80 lb
Non-Water Supply Well:
EMonitoring ❑Recovery 5 rt. g - 1 Bentonite 3/8'-Tremie Pipe Flow/12 lb
Injection Wen: 8 ft. 22 it- #2 Sil.Sand Consolidation Method/30 lb
❑Aquifer Recharge ❑Groundwater Remediation `49.SAND/GRAVEL PACK if applicable)
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
5 rt. 8 rt. #2 Sil.Sand 20-28 Consolidation Method
❑Aquifer Test ❑Stormwater Drainage❑Experimental Technology Subsidence Control ft. ft.
20.DRILLING,LOG attach additionil sheets if necessary _
❑Geothermal(Closed Loop) [--]Tracer FROM TO DESCRIPTION color,hardness,soillrock typa,grain size,etc. W
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 ft. 2"Topsoil-Dark Brn Silt
4.Date Well(s)Completed: Well ID#
01-30-2023 MW-5 1 ft. 4 -ft. Dark Brn-Grey Elastic Silt
4 ft. 6 ft. Grey Saprolites PWR frags Qtz-Granite
5a.Well Location:
6 rt• 8 rt• Grey Gravely Sandy Saprolites
Sam's Mart No. 74 00-0-0000035588 Inc#48068
8 rt• 14 ft. Grey Gravely Mix Sandy Saprolites
Facility/Owner Name Facility ID#(if applicable)
9810 UniversityCity Blvd, 28213 14 rt• 20 rt• Grey Clayey Sandy Saprolites
y Charlotte, 20 rt• 23 rt• Same CISA-Termination/Refusal
Physical Address,City,and Zip
:-21.REMARKS`t,' "i4_€. g;m
Mecklenburg County 5112105 0 to 17-ft 2"Sch 40 PVC Flush Environmental casing r
County Parcel Identification No.(PIN) 17 to 22-ft 2"Sch 40 PVC .10"slotted screen w/Molded cap
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.18 29.63 N -80. 43 10.84 2-3-2023
Si f Certified WAII ontra or; Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a 6pair to an existing Well: ❑Yes or ONo copy of this 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#2I remarks section or on the back ofthis form. 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 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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 22.5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 18.7 (gt,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
4.25"0/2" I 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
11.Borehole diameter: (in.) i g
425" auger-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
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 Wate i Resources Revised August 2013
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