GW1-2021-05692_Well Construction - GW1_20210727

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WELL CONSTRUCTION RECORD �
'Ibis.form con be oxd.fflt s' Pot itYemot Usc ONLY:
tn8#cor ttaili�k n�c[Is
1.Welt Contrwor infortuatiow..
Brian Swing PR Ml10 005 t►"Ols
V6,41 colftcwKanle It. n.
4240-B
r 5:40 .R- [1Rtt7 (nlriuft iirlt 'iOR[> iit: 11cab
NCItcJfCotAtaaorCeniftcelionl*fsu�tcr
FROM TO ntAMFTRR T"Kll%TM MATERIAL
SASDACCO Inc 0 h. 21 (L 2.25" ie. NA STEEL
CQ'a 1,9111'NatnC'
PROM! TO VMFTER I Tt11CTTM7M MATERIAL
2,Wdt ConSttactlon prxmlt t WM0301134; 70002898
lid altappfiroiblr wvlf pr oltR(er Cowi y.Scutt'.liadamr.lffenYDi at )
3.Wdi'usc(chectcwdhpse): ?Water Supply Weil; PRO"W1 TO I ntAMETIM I st or 91VZ 't111(Y 0-," I VArFMI61
©AMiniltmal 0Municipal"lic 21 R. 25 f6 1.25 fe 004 STEEL
OGeodwmal(Heatingtooling Supply) DResideutiul Water Supply(Smgle)
Qlndust►iai(Commercial OResidential Water Sl t tOlfii - ;:
(pjll)'(Sl&nL"d) FROM TO zMA7BRG►.L I
KbMAC9MVffmvmm&AMOUNr
01nijMWn IL (L
Non-Water So ppiy Well:
®Monitorin t]RccoA
FQjeC1lOn ell: rl, rL
OAQnifer Rccbarge 00mundvMa Rcmediat on ,1 .;AN 1* . : 77
7-
rRom TO MATRRWt. i RMN .il•„M t711y9
DAquifer Stgtllge and R"vvy Milinitr Barrier n. (L
OAquifcrT'est OStoltlltr:itV bmtriage ft. (t.
O>:wrimcntat Tschnoloa ostdlsidencc Como!
GGeothermal(Clow!Loop) OTrecer om To nt�eRtt rt oskr ewrs" tatraste n eve
Meothermal(ReafingCooftRemnl) DDllkr(etplain under 0 (t. 20 fL FILL SAND/SILT MOIST TO WET
20 R. 25 (t. WET SILTY SAND
4.Date Well(s)Completed, 7-7-21 Wti1)DRB-2 R, tl e
sm.Well LAlCatimt: n, �
Bill Jarrell's Automotive (t. (L wi
FacifetOmmNsmc Fwtlk WNCirwpucaw) R. ft.
res . 1,j111�
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4830 Old Pineville Road, Charlotte, NC, 28217
/� it R. � �t10n �YiOh
Pksiml Adds,Crty.and Zip
Mecklenburg SP-22 WATER SAMPLE VIA DPT TOOLING
(`AMMY PAMd lderd,fecaden:*(PIN)
Sh.I,ittititdc and I ongitntk In Ile)tt':cstmlmttcSJsccrindsorder lmal tee ttcst Ceilifieation:
(gti4ttf fietd mle taClo�is s�dl}cirm)
Brian.. Ewin 7/14/2021
SlgW to of C dfMd WCH t7ontracmt 1} e
6.Ts(are)the weli(s): t 2erroanent or OTemporery
Ur signtitg�fermis t herrb}cYhNfK thar n'u rrll(a I�t�+'f iturtrtiutted in nrio,�fnnrr
4415A NCAC 02C Al001 or.15A KCAC.SIC;0=tyre!ConatttuWam 3tendnrda and sw a
7.Is this 8 repair to an+exlong well- Oyes or MNo ropy of thlf rmrrrf hWs bim g+m'!"to#tie»rli ofiner.
kshis it a te7wor,fat 4mI bxirm%Wt comm yto"ljonwtw w d rxptaln the mwe of rfw
reywirwrdrr#21 rvnarkr xrat n or.on the bari ojthfr farm 23.Site diagram or additional Kell details:
You may use the bade of This page to prOtide additional`well site details or!yell
S.Nmnber of wails uottstrncted: 1 cotssuuction details. You tree,also attach additional pages if necessary.
Far.nrdjiple h*ed jof nim-it)wrAip#y yrtls ONLY%frh Ar tameransdmrllOar,raw Imo SLiBAiCI"l fN �170NC
Aubmrif one form, S AL y T9
9.Total well depth betiow land surface: 25 (tk) ZtJ Por All Wells: sSi6ndt tWs farm witlilo 30 days.of c otnpletion of nYll
Fnry�ruiNp;r ticli#tellAeprhrh(dtJjerectifenrrnrfc 3�31N►'ctrut3E1R i'► con5tructiontoftfplloningg
'10.Static Water leeM below top of casing: ( ) division of Water ReseuIrti&In nnstion Processing Unit,
rf w+erer kvrl if dbesY ed&j'f..eaM"a" 1611 Mail Sa vioc 0 rater,ytaaW*NC 21699-16i3
it.I3ordxolC a'iafiticr:2.25" dal 24b.£or in[txtinn We11s ONLY. In addition to sending the form to the address in
246abol`e, also s0mit a copy of this form tritilin 30 4%of,completion of trill
M Well construction mobod:DRIVEN cmtilltxion to ft f llwAng:
(i&auS r.rotary,eabit diycd;Osk c6e.) .
Dh'ision of WaterRmurces.Underground Injection Control Program,
FOR WATER SUPPi.Y W I.LS ONLY: 1636 Mail Sail&-Center,Raligb,NC 276994636
13a.Yidd(gpm) Naboil of test > F0r Water tQlWV& nja;tfms! ' .
Also submit one cap}'Ofthes lbrm"',%Uhin'30 ftsofcompletionof
13h.Diu utwfinn . ie: Amount: well c e nstn l 1 dew malt of(he coonly irhtic
' h'Y
�r�elt consUttctton to the cwmty tleaith^ tt
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Farm t"lV-t Nonh Catclins Dq mtwd of F.miioa t aid Naiutal Resompcs-;Di<zsion of l['aic�R Rcclstd A+i t 2013