GW1--03036_Well Construction - GW1_20230310

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Firas Mishu 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 28 ft, 30 ft.
4461-A ft. ft. j
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
M&W Drilling, L L C FROM ft. TO ft. DIAMETER m. TRICKNESS MATERIAL
Company Name
70003120 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: FROM TO DIAMETER
List all applicable well construction permits(i.e.WC,County,State, Variance,etc) 0 It- 16 ft, 2 in. SCh 40 PVC
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 15 ft. 30 ft• 2 in. 10 sch 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft• ft in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. None
X Monitoring QRecovery
Injection Well:
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 13 ft. 30 ft. #2 Filter Sand Tremie
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) 'Tracer 20.DRILLING LOG attach additional sheets if necessa
RGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks)J
FROM I TO DESCRIPTION color,hardness,soiVrock type,grain sae,etc.
0 ft 20 it Brown Soil
4.Date Well(s)Completed:2/21/23 well ID#TMW-3 20 ft 30 ft Gray Rock
Sa.Well Location:
Johnson &Wales University
Facility/Owner Name Facility ID#(if applicable)
713 W. Trade St., Charlotte, NC 28202
Physical Address,City,and Zip
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:
35.231967 N -80.849399 w
6.Is(are)the well(s)OPermanent or XNTemporary Signature of Certified WeliVontractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or )No with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
trihis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 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 d�erent(example-3@200'and 2@100') Construction to the following:
10.Static water level below top of casing:24'.8 (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 infection Wells: In 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.)
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&Iniection 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. j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourices Revised 2-22-2016

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REFERENCE:AERIAL PHOTOGRAPH-JANUARY 27,2023 ,
GIS BASE LAYERS WERE OBTAINED FROM MECKLENBURG COUNTY AND _ TEMPORARY MONITORING WELL/SOIL BORING
NEARMAP/DURHAM COUNTY. ALL FEATURE LOCATIONS DISPLAYED
a
ARE APPROXIMATED.THEY ARE NOT BASED ON CIVIL SURVEY Q SOIL GAS IMPLANT(SGI)
INFORMATION,UNLESS STATED OTHERWISE. Yf SUBJECT PROPERTY
3
m
0
SCALE: FIGURE NO.
SAMPLE LOCATION MAP 1 " = 50 '
DATE:
713 WEST TRADE STREET 3-7-23 3
CHARLOTTE, MECKLENBURG COUNTY, NORTH CAROLINA PROPOSALNUMBE
22350316A