GW1-2021-02702_Well Construction - GW1_20210512

WELL CONSTRUCTION RECORD I For lntenal Use ONLY-
This fonncan be aot.•d far single or multiple v%vils
1.Well Contractor Information:
'iJ..1TA Y.ONF�
Zach Thompson FROM its In Sr,N1t=imt
Nr01 Coutraclor Kann
4478A
NC Well Comractor Cenif nation Number 15:OtlTER CAS1hiG Cfor eiuNS easirl well_ OR]Li11TR(If a'-"fJeahoc)`=
FRO'! TO DIADIF.TFit TIItCKNEiS MATERIAL
SAEDACCO Inc 0 h, 11' (L 2^ ic. SCE-40 PVC
Cor*uii-Karttc I6. .R CASfN t) TUB]XC iffM&AIiA elbscda6h ._
FROM TO DTA1W_T6R.- TMCKNRSS MATUML
2.Well Conamet tin Permit d: tL ft. i1L
Lief Rif n�rfirn6le teeillrrrmirs(is.:GnXatu,>Stae,trnrinrtce,ftiy�d'ert er-,)
3i W4011 Use(check well psc): 37 5' NCicN :mot j am.
Water Supply Well; FROM To m1AMFUR i AT9l7,t; 'rtttMM''S I MATr.RiA1,
DAgrkultu al MMnnicipaltPubliC. 11' ft 21' ft 2^ in.' 0.010 SCE-40 PVC
OGeothenrol(l'leMilg/Cooling Supple') ®R.esiderilial Water Supply(siDrlc)
OlndustriatlConimcmial ®Residential Watsr Supple'(sluTed) "28:CROIf1
FROM TO MATERIAL EMPLACEMEWAfUMODSAAIOUNY
0hrigation 0 ft. 7' fL Portland C tection
Non-Water Suppty Well: tt. tL
0",tipg ❑Rccmrr)•
injection Well: (L h
0AquifcrRecftarge cGroundnnter RCmedialion t4;SAN1t1GRAVEI,'• A if:''liiir tc7' _
❑Ago)fcr.Stor rFFc alyd Rrxovrl7 ❑Salinity l3arricr rRt)at 'm MATFRIA1, Rnrt at*:xr�sr MrrHOn
9' ft. 21' fa Filtered Sand #2
❑Aquifer Test ❑Stor m-RtcrDn,161ha'-C
ft. ft
❑E.Vmmcnhi TechnoloyW 0SA5idcRCc Cordroi
20;=DRILL.arO'LOG(Aiiaerl'adriifinnal abeefst:ncceFcAn•
❑CK,othemuil(ClossdLoop) ❑Tracer .FROM TO DFSCRIMONfwbr:hFr4nen:toi4mcRtr n*P,dcm
❑Geothentral eatiao'Cooline Retunm) ❑Other(explain under t121 Remarks) 0 ft. 21' (L Brown isilty Clay
ft. fL
4.Date Welts)Canepleted: 4/22/2021 Wdl mpMW-17R
t4 fL
5o.Well UIC261n: (L (L e�
Brownsfield Site rL tL
Fact1hy/OuncrNume Fscil*-lDY(if applicablc) L q rl
L
ft ft.
4800 North Graham Street, Charlotte, NC, 28269 R rL
Pt)tsical teddies.City.and Zip 21 REN ARK,'" ,57 t till
Mecklenburg Bentonite Seal from 7'-9' DVVK b161;0,11'
conauw t ANO td=*ntitiwatiao:Np;(PIN)
Sh.Ubtude And Longitude in degme0mim ites/seconds or dceiniAl ftr;ccs: 22.(:ertifrcation:
lifaell field.one 1a&lotgi3 SWTIC;c(d)
35.278963 N -80.805034 R' 4/22/2021
tgn3trir.ofCeitlticd t4'e Conunctar .� Date
6.is(are)the well(�Y $Permanent or ❑Temporat'y itr'srgnfn,s ahiirfeir?n.!hereby certify di}u rlae n+el)ls7 idads':(krrrJ c1cn37ruC1edf ar m.'r^raSmr:r
sdrh 1,54 XCAC 02C.01(k)or 1SA 1NCAC MC.(i20D Well Coarstraafwt Standards dvid xiwt dr
7.Is this a repair to in existing well: 991ec or ❑No rY p)•of rhli rdv mrl Ana lxrvr pmriNr7i rn)far ti�rf1 neater.
If Ols'k a egvir.fflf O.ve krol 9a well tonon(Mo a brfomur iar irad expfrah rite mnfnre of the
repair rarder#21 rrmarks sre-1im or an Nis bra-k r.!fthis ferur. 23.Site diagiram or additional well detaik:.
You n1ky use(lie back of this page'to provide additional well site details or+yell
R.Number of wells cominicted: 1 constntction details. You may'also ftuach additional pages if itecessary.
For matfrib le infoerhut chi urea-mwee W4,v audit ONLi'w1di the mme cnrtsOucdlmt,vcw can
smAwvdr+re farm. SUBMITTAL INSTUCTIONS
9.Total wdI depth baton land surface: 21 (A.) 243L For Ali Welk Submit this form uidAn 30 days of.comptetion of aril
FcrnrtifrWewrlislisrallrleyrhsffdrf rviir(rrmwrrfr-z@:0.o'aru!?urlffr+'1 constmcOvntptbiefolloAing;
lei.Static winter level below top of easing: (ft.) Division of Writer Resdurtes,lnformition:Prveess4ng Unit,
If"mr Rwel it aN ne rdsioag,us:"+" 1617 Atait Service Center,Rrleigh,14C 27699-1617
11.Enrc6nM diameter.8.25" (in.) 24h.Fnr inlMlian Wcllc ONL Y:j in addition to sending the form to file address in
24a above. also subfiiil a Copt' of aids foci within 30 dtn'S of completion of%veil
12,Well COAMMCtlon"XIbod: Bored c'onstmrcNou tothe.follouri e_
(i.e.aura.rotan•.cable.dirxt push etc:)
Division of Water Resou tees,'Underground fnjection Control Prograin,
FOR WATER SUPPLY WELLS ONLY: 1636 Alail Service Center,Raleigh,NC 27699-1636
i
13a.YfdA 24c.For Water Supply alt'lnloctGiei Wells:
(ftpm) A1Cthod of test: ,also submit one Cope'of this fotin'wvithin 30 dae's of cotnoletion of
13b.Disinfection t)pe. Amount well constriction to the county health dgmitnnart of ibe County where
cprtStniCtcd. �
Form G1V-I Nash Carolina Dap nimra l of Environment and Natural Resources-Dht ion ofSVaicrAon- Revised August'Y)1.1