GW1--01251_Well Construction - GW1_20240229

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NON ON RESIDENTIAL WELL CONSTRUCTION RECORD
`A+ o; North Carolina Department of Environment and Natural Resources-Division o$Water Quality" av .- WELL CONTRACTOR CERTIFICATION# 2717-A ;,
1.WELL CONTRACTOR: d. TOP OF CASING IS N/A FT.Above Land Surface*
Jay Little *Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C.0118.
Well Contractor(Individual)Name
S&ME, Inc. e. YIELD(gpm): N/A , METHOD OF TEST N/A
Well Contractor Company Name f. DISINFECTION:Type N/A Amount N/A
STREET ADDRESS 2016 Ayrsley Town Blvd, Suite 2A g. WATER ZONES(depth):
Charlotte NC 28273 From N/A To N/A From N/A To N/A
City or Town State Zip Code From N/A To N/A From N/A To N/A
(704 )_ 523-4726 From N/A To N/A From N/A To N/A
Area code- Phone number 6. CASING: Thickness/
2.WELL INFORMATION: Depth 1 Diameter Weq iV8rial
SITE WELL ID#(if applicable) ITZ-31 From 0 To 42 �. Ft.2-in. sC Ir'V
STATE WELL PERMIT#(if applicable) N/A From-N/A—To-N/A ti rt N/A _NIA N/A
From N/A To N/A Ft. N/A N/A N/A
DWQ or OTHER PERMIT#(if applicable) SIP 70001078
WELL USE(Check Applicable Box)Monitoring 0 Municipal/Public 0 7. GROUT: Depth Material Method
From 0 To 39 Ft. Neat Cement Pour
Industrial/Commercial❑ Agricultural 0 Recovery❑ Injection❑ From 39 To 41.4 Ft. Bentonite Pour
Irrigation!: Other E(list use) Air Sparging
From 41.4 Tom 7 i Ft. k-packer N/A
DATE DRILLED 2/7/2024
8. SCREEN: Depth Diameter Slot Size Material
TIME COMPLETED afternoon AM 0. PM In
From 42 To 52 . Ft.2 in. 0.010 in. PVC
3.WELL LOCATION: From N/A To N/A N/A
CITY: Charlotte COUNTY Mecklenburg Ft. in. N/A in. N/A
From N/A To N/A Ft.N/A in. N/A in. N/A
Mount Holly Road(MCK Terminal) 9. SAND/GRAVEL PACK:
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) Depth Size Material
TOPOGRAPHIC/LAND SETTING: From 52 To 56 Ft. #2 filter sand
0 Slope ❑Valley tgi Flat 0 Ridge 0 Other
From N/A To N/A ; Ft. N/A N/A
(check appropriate box)
35.2797 Maybe in degrees, From N/A To N/A Ft. N/A N/A
' LATITUDE
-80.9422 minutes,seconds or 10.DRILLING LOG
LONGITUDE in a decimal format From To , Formation Description
Latitude/longitude source: XGPS o Topographic map 0 39 ,Silty Sand
(location of well must be shown on a USGS topo map and 39 56 ,granodiorite
attached to this form if not using GPS) I
4.FACILITY-Is the name of the business where the well is located. 1
FACILITY ID#(if applicable) N/A
NAME OF FACILITY Products Pipe Line Corp(MHRG) .1
STREET ADDRESS 6869 Freedom Drive r '
Charlotte NC 28214 FED 2 V ,021
City or Town State Zip Code
rm ka,mr3M
CONTACT PERSON Greg Dempsey ea 2 Um.
MAILING ADDRESS 1000 Windward Concourse,Suite 450
Alpharetta GA 30005 11.REMARKS:
City or Town State Zip Code Sparge well is direct buried.{Water level is approximately 5 feet
( 770 I. 751-4153 bls.
Area code- Phone number
5.WELL DETAILS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C,WELL CONSTRUCTION STANDARDS,AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
a. TOTAL DEPTH: 52 feet 7 Z? (7 4 2- (`/ -2el
❑b. DOES WELL REPLACE EXISTING WELL? YES NO X SI NATURE OF CERTIFIED WELL CON RACTOR DATE
c. WATER LEVEL Below Top of Casing: N/A FT. Jay Little
(Use"+"if Above Top of Casing)
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW-lb
1617 Mail Service Center—Raleigh,NC 27699-1617 Phone No.[phone] ext 568. i Rev.7/05
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