GW1-2021-02359_Well Construction - GW1_20210527

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WELL CONS77tUCTiON RECORD For taocr,atl Use ONLY:
'Mis<formcon beuscd.fnrairgloor rnu]C+ykwdis
1.Well ContraetorlIntotmat(orr.
Brian Ewing rR MTO I D Tnlov
Wolf Cordraaw tOrm ft f1.
t4 ft,
4240-B
NMOICommdorCertilkationNuirber i OII7Pdt ti tit tinitl�ei7itl rtA ;4R;'if�rl t. b`
FROM I To DiAm" . T[fK%, M MATERIAL.
SAEDACCO Inc 0 (L 20 tt. 1^ In. SCH-40 PVC
Comtmry Atxetc
FRO. DIAE VnR I TRKIMIMMATERIAL
2.Wad1 Crinstrrrrxinn Permit#: 70002872
first oideA{ifirvbtr wNf penal((ti e:Cmima,SAW,varia+wx,Irfecdon fir.)
R; fl. iiA.
3 Well Use(cbeck ivell use):
Water Supply Wdl: FROM: TO I DtANKUR SIA7-U. ` ,itnC"1ss . MAIMIAi.
C1AgLicatl[utal 1WliufnnicipallfrClbliC 20 ft 30 0. 1^ 1& olo . SCH-40 PVC
DGeothermal fHeadrot v1in8 Supply) OResidential Water Su"bt(single) ft. It I im
DindustriallCommetriai OResidential Water Supply(s)wed)
FROM , TO MAT8RtAL RTMACF.MITAtVMODkAMOUM
01ni ruion ft. M
Non•Water Supply Will:
MMonitonn DRecot tt. tr.
lDJOoit elt: tl. fC
C3ActtnterRscltafge ElCrroiandm�tctRctrt�liatton tr:'SA +
FROM, rimy*tAI. itAtlrA rlir N o
E3 Aquittr Stomsc and RowlrTy 0SPlinit}Banicr 18 IL 30 A. FILTER SAND # 2
0Agttifcr Tcst Castoirmtil Cr D-TalnAgC
(t. ft.
ClExperimcnlal']cchnotogy 0subsidencc Conhot
oGeotlterttml Closed O.�illttUtAt� �tYirsk`li�+ilal(ro>tff tieirfd9f� � w-
( Loop) b7�ifcer vRarz TO DiG4CRtFLiO�oslo►�.�� roaPHnit ru l
❑Geolkintal(Neau 1tW Mum) 00det(60ain under#21 Rem&&) 0 (L 30 11. FILL SAND/SILT MOIST TO WET
(L. (L
4.Date Well(n)COmpletede 5-6-21 Wdt.]D#TMW-1
fL tL
o !f"
so.We"tAcation: (L n,
Auto Parts Salvage Yard ft. rL.
reciliiy:.10%-wrNnmc (sroWirablel
1118 W. Craighead Rd., Charlotte, NC, 28206 ,
r n Pro.. ssm.
F otial;Addxss City:and Zip Zt„ttCttt , b,
Mecklenburg BENTONITE SEAL 16 TO 18'
Cca[fty PORCi 1drMlfltiUn Pfo:(PIN)
5h.l atitude and l vngitade in degrees nninwtWsce Inds or dechnal tides;
(lraeti Ikta,of 1*10gg)s(+dodo d.)
N W Bru n awi ng: 5/12/2021
Sigmt m arceltifica Weti Contra T Dace
6.Is(arc)the»cll(a): aPermanent or zTemporary Br.+igitdnx INS foV1 J hen+by e*h*rhw t w U'r4s)+wtr(w ov)writrnwmd is arranl'nre
with#SA NC4C 42C.01M or 15A KCAC.02C.0200 IFrtl CaastrwTim Stanrdarat's and Ara a
7.h this n repair to an existing well- 0yo or ENtt a oprtlf�+If JBYdrd fats$eera JlitYilfflYt t?tYAr HCdf axv+rr.
{/this)r a repc>fr.Jldl ON fi wtm w'rg e0swMatm!'+f)'orwratlirn:ad rAO014 the mrmra of thr
"Wlran derA21 r,anrukse"hw ar(H the bad o/rh&1wA. 23.Site diagram or additional well details:
You Flay use the tv&of this page,to 0mVide additional well site details or(veil
8.Xomber of wells constructed: 1 construction details. Yotl may also attach additional pages if oecesswt
For mm1dj le lrtjc;W or nrarn;eter z p#y(nits ONLY ndrh the smnr ponsbwr�far vox con
mbodi enr foam SURNMAL.INSTUmms
9.Total well depth helow land sttrfaee 3 0 M) 24s. Per An Werra Submit tills fonn ttit]An 30 dkn of completion of t►tll
For mftWo,wxfit tilt all drrAr VdWerrw(eawfe-3 @200 erad 1 0 1W) constriction to the folloning:
10.Static water level l dow top of casing: (e•) Division e(W ter ttesoun:�,Intortnmion Proressing Unit,
If wwter hwl ds mbove eddn't,w„+' 1617 wan Scr viec Cater,Rslcio,NC 27699:I617
1L.t3orchntc diatnchr:2.25^ (in.) 24h.Fits EQ KWIln Weifs"Otci l'. to addition to sending the foml to the addnw in
246above. also submit a copy of this fort within 36 days of completion of well
12.Welhmnstrimdon method:DRIVEN crni Metion to the.tbllowigg:
(%t.s iW.mbsy.ably din d posh etc.)
Division of Witer-Resou ras,Undergmuad Injection Control PLrng vM.
FOR WATER SUPPLY WELTS ONLY: 1636 Mail Se'vice G"Itr,itrr'00.NC 2769941636
Ur.For Water:SoOpIX&1nimdoA:Wells !'
132.VIM(germ) rKethod of tcst
.Also siibtnit one cxtpp of this fonh tsithrn;=0 days of completion
131r.4191011"on tJpe:, Amount: well canstndction to the ccrmty'he'.alth,depsnmem of the county what;
covamctod., j
Farm MY-t Nonh Carolins of Einimnnwa and Natural Resoums-:Divkba of Wala Rlew roes Rni AtIgLd 2013