GW1--03030_Well Construction - GW1_20230310

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WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Firas Mishu 14.WATER ZONES
FROM TO DESCRIPTION
�4 ell Contractor Name
4461-A 27 ft 28 ft
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells TOIL if a licable
M&W Drilling, LLC FROM ft• TO ft. DIAMETER m• THICKNESS MATERIAL
Company Name
70003120 16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM ITO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.b7C,County,State,Varimce,etc.) "ft:
15 ft' 2 in- SCh 40 PVC
3.Well Use(check well use): ft' in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL.
Agricultural QMunicipal/'Public 15 ft' 30 ft' 2 i" 10 1 sch 40 JPVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft• ft. in.
Ind ustriaVContmercial EJ Residential Water Supply(shared) 18.GROUT
_11irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' ft' None
X Monitoring Recovery
Injection Well: ft• ft•
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 13 r` 30 k #2 Filter Sand Tremie
Experimental Technology Subsidence Control
Geothermal(Closed Loop) [:)Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soil/rock type, rain sae,etc.
Geothermal(Heating/Cooling Cooling Retum) Other(explain under#21 Remarks)
0 rt• 20 r` Brown Soil
4.Date Well(s)Completed:2/21/23 Well ID4TMW-2 20 r`' 30 r`' Gray RoCk
rt. rt.
5a.Well Location:
Johnson &Wales University
Facility/Owner Name Facility ID#(if applicable) -
713 W. Trade St., Charlotte, NC 28202 ft. ft. < <
Physical Address,City,and Zip ft.
Mecklenburg 21.REMARKS _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.232105 N -80.849251 W acts Z,13
6.Is(are)the well(s)oPermanent or E]l I eniporary Signature of Certified Well Nntraclor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.U this a repair to an existing well• IDYes or E)No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill ow known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100') construction to the following:
10.Static water level below top of casing:20.94 (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:5-5/8 (in.) 24b.For Injection Wells: h►addition to sending the form to the address in 24a
Air Rotary above, also submit one 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.)
DIvi5100 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 SuDDIv&Injection 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 G W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016