GW1-2021-06373_Well Construction - GW1_20210915

WELL CONSTRUCTION RECORD For irrtcrml Use ONLY:
nis Conn can bc"uscd far sine or multip)c"tits
1.Welt C ntractortntarthittion:
IA.A A T-k2t1'NES
Rich Lemire FROM Tft I DFUNWHI "ON
Hr�I,Curtbtrrgari�unrc R. rt., ,
2593A p.
NCWelIComiacaorCcnificstioaNsur ib ca 5.OUTER CAMMING orinthkawilrren.- RIJNFR(ifHI a ticab
MUM TO DTAMFTE; TCKNESS MA7T,PT.AL
SAEDACCO Inc (L fi. iOr.
Cfrava-fly Know MINNER CASM6,03tTUBING`(6oiheridAclowdaol
FROM TO DtA IETRR 111CKNEss AIATT RLAL
2.Wit Construction PcrDaat r* 70002060 0 ft. 21 G. 2" ?'tlE SCH-40 PVC
GirB tdl.rl�nlir w44Jrt weft peimldx If,_r.>County.�Stwe;Ma dnrr e,Trrftrdcg M-'j
23 ft. 25 ft. 21, SCH-40 PVC
3.Wcl U.k Ykak titiTl1 tascl:
Water Supple Well: - --- - FRUrt 1.70 -0 wTarrr$ IMIMMS I MArKMAi.
DAgricuh#ltal ic 21 ft. 23 A, 21, in. .016 SCH-46 PVC
OC,eothennal(Vetatin oolin St ly) OResidential Witer Su [t.
8� S >f>P pPh'fsing�c)
Oludtrstriali oninietcial OResidential Water:Supply(slvmd) 18XROUT ti -
FROA1 •TO MATERIAL MPU MS1110D&AMOtNT
❑ldi Htipn 0 ft. 17' ft. PORTIA= POURED
Nor-Water Supply Well:
Omon'itnrin ORaxntr fi
Injection Well:
OMiti(cf-Acchairge e6M)Ml4131er Rcruiediii6on :'$AN[rdt:[tA:. :.ACV
FROM TO I FfATrYta'N11, 00 ,-tr't M.- oil
❑At Ilifcr$tor tc OTO R,ce(rVCIY 0S,1linily l3omcir 19 ft. 25 f1, SAND #2
i3Aquificr Test ❑Stomm;atcr ljrail,7�c
rt. rt
❑Experimental Tocuotogy bStdasidcabcc Control
TOA�IfRltA.7l1i3laflCr-toittiehadititia�isildlier`.ia�ra►eTiss�rrti�
13Q.0 heamai(Closed Loop) ❑Tracer F110111 TO DI r.Rrt'770x br,lra�dnes+xr4'nrckn �r+c Na
oCi^.dtlletl5bal Teaffig.OR Mum) ®Giber jt! in under 921 Retawks) 0 fL 14 fL RED SILT/FILLDIRT
14 ft. 25 fL SAPERLITE
4.1)ate We[t(rs)Completed;, 8-12-2021 Wel1i ID#ASW-82 ft, fL
5&Mtell Lormthid. ft. (L
United Parcel Service ft. (L
FacF1dyPX)i-ncr Name Facohy mm(iropliaiblc) w
1600 Cottonwood St., CHARLOTTE, NC, 28206 ft. (i.
P7p5aenl'Address.City.and dip 2 L REMARKS 1[
MECKLENBURG 07714104 BENTONITE FROM 17' TO 191 . rgc,Sl
tbtrtrty 1'Aftd ld=ra,irvalljort No,(PIN) `), SSG1.p(i
QQL
56.Latihtdc'and Longotndc in dcgrecOminutcslsm.nds ordccimal dctrvvi: 22.Certificatio
(iftsitt,freld,rir'rc:I,iA, ou Is srd7le#firrj)
N ,' _ V'1` .�Qras�-lam 8/15/2021
Si to tUM ofCt#tLrV d4ell CO9=t0T Dac
6.Is(are!the well(s)t EPermanent or OTemporary ty siggAning 1hfr,rSdPrm,f here1n,cer*(h' of Wx mW110)rswx rr*;tl ewatnrcted 1rr n lod"I mee
ivhJY 154 NCAC 02C.0100 or 154 MCAC 02C.-0200 Well Conirmedmt SrtaWdr,&and rra;rr a
7.Is this a repair to in'existing;n'cllf t71't,'c' or KNn cvpct�iflrtis rect+n3 tia ra 1 rq r;r&,rl r agar errs!ri�rirrr.
7f rlals`ls.n rerrerlr,fii7 otarfa,wirra uutf eansrrur-r?m�dtrforrarrlrrr mu#r.�pfn3ar r!?cvrmriare ofrhr
MMirredCr921 fM9rks:vircti6M&rm AC bat'oI'MiN fnrM 23.Site d1ragram:'oradditional Will detafl.4
You fl'4 use the back of tl►is pager to pfoOde.additional%vell site details Or welt
8.Number of wells conMructeed: 1 constmetion details. You may also sittach addiiioail pages if tr,'tessailr'.
For maWIde lnh+erkurar arm-tturee impplr wefts OjVIV t4rh ills snrttccaxstraetlwr,ycw.c4rrr
xrorbmii mir}nrra. - SUBMITTAL[NSTtICTIONS
9.Total wdt depth belmr9and surface- 25' {11.) 24a. For All 'I"k'lella; Sttbutit ties fanu it thin 30 days of coinpk4ion of ivelt
1°orrautrfpJew tJ /rAtar(7ctc7 ffdtfo'remtey4wAph at@1M'anti2@IMTt construction to(ltsfottowingr..
10.Static eater level below trip ofeasing: 15' A) Division of Water Regouirees,Ibtitrmation Prrot.'cssing Unit,
1f ivam-Wei is ague tijd ag.a "4 1617 Matt Sen•ice&dtcr,knlcigh.YC 216'09-1617
11.Bnrrhalc diamckv 8.25" (in.) 24b.For in ct-Mori ONLY: In addition to sending the fornr to the address in
24aaboup. also submit a copy, of this feral within 30 days of completion of well
12,Well con_stm-etion rrmAbod.AUGERS Lvnstruction to the fblloli inE_
(i.e.auger.'roiray,cable.dirm pusti ctc.) ' ,
Division of WaterResourms,Under0ound.fnjerticm Control Program,Wi FOR WATER SUPPLY LLS ONLY• i636 hfalt Service Center.Rale'W NC 37699-1636
74c.For%ter Supply&Inject,n iWctlss
13i.Yield(tsprn) MOM of test;
Also siuEbr hit Ole copy Of this Mini Nitlt►n-.30 days 0f conbpletion of
131b.Uisinfeedon tarpc: Amount- well constant Dn to the cutmty kahh d'Itmeart of the cotmtv-t4he-m
rnrisiraietctl.
Form G\tr-1 North Carolim and Nanur]Resources-Division of Wsler'Reach Rcviscd August 2011