GW1-2021-03347_Well Construction - GW1_20210603

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WELL CONSTRUC:`t'ION RECORD For►nemlUscON1_Y:
This rorm can be ewd rear sit*Qr maltit,le.nvus
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i.Welt Contractor Information: l
14 t1'A 1•iUIS
Brian Ewing FROM tit DF f`RIP.1`ttI!+.
1%101 CeIdF=wq tiart�e tt. ft.
ft, fL t
4240-B
NCYVe19Cc+tBmcrnrc:rnllnalianNviutrer 1#.11tt!1`l7t�C,14. [� rsrtttfttiKti9NliC 01iiFdL1"l�tlft Hc�?t1L.
pRryi41I TO PMNIF>M Tttttt+NiSf 7NA7�RiAL
SAEDACCO Inc 0 fL 5 fL 2" lO SCE-40 PVC
Cougianl Nartrc 15.' CAfi1lRt;t1R' D,. :,:. r�ad.tbi>zed tag
FROM T DtAMETER TNIMNESS 'A-WRIAL
z.well Ctni r surr _
1JstaJlfpV rcihlcx-41priwiftOx.Caugh.Steer,k'ririrrr�r.IttACGErb"at:.a ft> fL
Water Supply Well: Fa.dt r/tAttt9 r3t s t Tatty )OSS MA�'WAI,
�iAgl�ultorml t�lulutticipa4t@tdllic 5 ft, 20 ft, 2" .010 SC8-40 � PVC
tic Stipple) 0R�idential WaterStlpplti•(singlf:t
ft fL IL'
Dindustriat'Comntcicial 0R.e�idential Water Sul)ply fsbared)
PRoat To r<rnt75RIAL a nTtAMltMr t tErtroa s AetoLAT
pin than 0 ft. 3 fL PORTLAND POURED
Non-Water Supply Well:
®Manitatintt pRc�-ot
inje an welt:
n. t1.
CJAgoifcr-Rcch.•rrge oGranndmitcrRcoudiatian
Pao; m_ s►tntt trrAt VAJ tter�ttltr rtr3 , n
17rtclaifcr:gtPmp,c anal R4,x�aty ❑.SaljnW Barrier q 0. 20 ft. FILTER SAND # 2
❑AquiferTcst 0-44ommVer1hairiagc ft. ft.
❑E%perimanMl Tcahnolag CISubsidcrice C'onaml
ltl:RRl1.�Lii�Es1t>G'(attr>— .a4dllixirtila�rl��f �erti ..
oGmthermat(ClosWLoop) 13Tracer FRon 1 TO DFecrttrrlo~tcohe.lardriata.ruS'rrceter i :riz`
OGeothemial ftati2LCotfita Ratunit 130dicr(es lain urxkt#21 Remarks) 0 fL 15 fL FILL SAND/SILT MOIST TO WET
15 fL 20 fL WET CLAY SANDY
4.Data:Welt(s')Complt^ted: 5-13-21 We11 DdMK-3 ft. fL
5a.Well jutcation:
CA Body Shop rL fL
Fac Jhy,KYA-mr NanT- Facild)IDN(if atpl3mbte) ®" fL
548 West 32nd St., Charlotte, NC, 28206 ru ft. '®
Physical Addccss.Cin.and Zip t .
Mecklenburg SENTONITE SEAL 3 TO 4'
jw— it
Cawnv Nivelllftffitl=tttt➢No:iPINI
11i�.�(tr34tCn c ^y�iCn
Sb:Latitude and t ongitude in 4c%rv'cs/mimsh*1Wcandc or decimal dC9r�: ZL C - tiun.
01 udl reetj,inn:latrlong it.satkiew I
Brian Ewi'
T 1`, 5/24/2021
i�rutary ofCertdicd tLeil iatarinio p
6-IS(are)the well(s): Elten"Anent or ZITemporar}' By aiynin�this fepmt.1 hereh}re►re(s rkta the n•e1N,s't eras iweret rm ar:urelrcf in tirrzarrLarrr c
nta?1:S,t aVG'AC�7,?1''.+IIDi[d ne►5,1,NCrtf.tj�'f:it;-6t{!1{'c•!1 Crxrtstr•,rrf`rnI Satrwlritifii'et+tdfh�re ct
7.is this a repair to an existing w'dl: Mvs or KNo r vy Rfrhar re'roni lwu Iti m ln111-4 tl to tv nsll fnevier,
lr tl:ls i�ra re f>cr7r,lidi�esr krr�iwn feet!rnw.rrirt ercx,:+x�'irrauarFd,er mx,i ra�tlh,eac rltr tiurr,rf aJ rlie
refwir miler#21 rrmurfiv srntion ur nn the bad O'thk farm. 23.Site diagram or additional well details:
you may use The bast of this page to pto%ide additional well site details or%W11
8.Number or welts constructed: i — -- i onsutu:tian details. You nits}also attach additional pages if tx4xssary-
Fur rtxthp{ear;lera#r:�iw nrr i-rcicrttr tutf+4')'�uetls Old`{:Y n•br11 the rJtxrd Mna{t°trctinar,:•cK�c c�ro
satwnitsFRr frvre. St t1 ITTALINS`�tl�t'_33M
9.Total well depth below lanai surface:, 20 (D.'I 24a. Fur Ail Willa. Subtitit this form within 30 days of wmpt than of wall
For KWi4 it we;f list rrfl rfep*v rrWbrerew<sxam nle-30NN) ertri 2"11WI construction to she fottanigg:
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10.Static water 1►s'el irelow trip of casirIV (ft.) t0tt•ision of Water Resourrm Information Proeerdng Unit.
1617 Ik AH Service Center,Raleigh,NC 276994617
tfn'asttlt•3�tf r'saYtntvr rca�lrat,guru'•+" i
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t t.Burchotc disincter:8 Civ.) M.Frrr tntcetlnrt Wd L4 ONLV.) to addition to Sending the form to the addnss in
24a abme. also subtait a copy of;this form within Y) dins of ecentpla°tiatt of iWit
13.l4rcll et►r trttction rDt4b0d:BORED construction latt followinL:
ti.e.cougar.mmy.cabtc,dime pusk CWJ Dhislon of Water Remurees:i(nderground falmlon Control Prograin,
FOR WATER SUPPLV WELLS O LV.* 1636 Mali Strc•ice temtr.Raleigh,NC 276".1636
24C13a Vivid(AIM) Method of test .For Water Sa lit ilk IpjecY 1 Wills:
Also submit off !°of tbls four r within 0 days of completion of
13b.Disinfection h Amount:„ _ ,a „, well construction to ftcaunOv licalth depanrnr-M of the cotmly Where
he: constntctcd
Fmm Ce�kr.l NVK*i Cototua Dep mearir of Envin*> eei aced Nnntrat R-u urccs-01%tuan of%Vatcr Rezur t RO-M AWAst zip t1