GW1-2021-06349_Well Construction - GW1_20210915

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,; IELL CONSTRUCTION RECORD Far latcrnot Use ONLY:
'(lid rrrm con be u-wdz W siagk or na[iVk nr®s-
1.Will 6ntraetor Information:
11.AV ITR ZONES'
Rich Lemire FROM T[r bE4('RrpltO\ 's
*1411 cur-an NA" fL ft.
2593A
Wt=We]ICammetorCticnifecetionNumbcr 15.OUTER.CASINGI .orimiTikasoil*W 'ORi.NTRfif`a'
FROM TO DTAMETER 11 T®rCF:NF$S hTATEPTAf.
SAEDACCO Inc (L. tL
t:egr�q�tmg:Nan ]6 JNNE-R CASING OR 71P81i�7G �ihcittlai�lnictlaiiii
FROM TO DIMIETER !TBICKNESS I MKTUUAL
2,Wet[�anstructign P.crm, : 70002060 0 fL 21 ft, 2" SCH-40 PVC
I-W4r1t*T � rr16lr WV41prnmitx(rc:eomm y:SMte,.t+driarwe.1QAT irl ern,) 23 rt, 25 tl+ 2" iM 11
' SCH-40 PVC
3.Weil.Use(Chccl;wdl peep:
Water Suloply Well - FROdt Ito I IA74FIrvztt IStAaTSIM I TMIC NM MATERTAT•
DAgrk.ultu al 0Mut I0-'paJ{ )iC' 21 �f� 23 f1 2" t�• 010 SCH-40 PVC
Metsfllca MI(tJV-10n0taoling'S'tTplvr bResidential Woter•Stippb'Isingle) rt
171tidusttialrContmemial DR4sidential Wmr'Su (shared) IS.-GROUTr4
( FROM JO MATRRGL Et►TPLACE MI N`t ME frf OD&hA70tIYT
ohin ration 0 R. 1 17, tL PORTLAND POURED
Nor-Water Supply Well:
❑Monitogn l7Rc�cssc tt 1L
InjecitoTt Welt: tc tL
0Ague(crRecliarse t ti►ouTrdatutcrRcatcdint3on t AND t (M.T.;"itl',L3iile)
pAilatofpr:Stortgc mud RcciaNrty p5;aliniiy Bamcr
19 ft. 25 rL SAND #2
❑Agtrpl`cr�'�. O 1omm pater Dm'►nalgc
rt,
bE cperimcnhal TbcUology DSabsidca cc carom) ft.
311,:RRi1.UKG LBG failacb:idriltiai of;7ectis$raicccacen}
[7G.oilverflial Cirtsed Loop) O f Ctr .FROM TO 11MCRTPTTON Color.lherdnert W11mckit d Am t*
❑Goothemial ELafh e2o2inge,Retutm) 30tig{. ait1114id&#21 Retbaft) 0 tt. 14 rL RED SILT/FILLDIRT
14 rL 25 fL SAPERLITE
#.Dato Wells)(7ompleted: 8-13-2021 WdtjD#ASW-84 ft fL
A�
ia,WclIcatniu: 2 ft (�
United Parcel Service R tL p
FacIF ftyi0wncrTlame Fasdils IDS Grapplicnble) rr rL C
1600 Cottonwood St., CHARLOTTE, NC, 28206 (l. 77j7777u;
lr1f,4ik lAddmgS 01y.mmiZip 3i li!'.I►t�1[ICS. I.. jr`jT-.•_..
MECKLENBURG 07714104 BENTONITE FROM 17' TO 191 .
Ctitttilt° IT7ettd ld?'tdal�eiiiian Ne,(PI-f@)
+b,I�;ttitudt antl,LringittTdr,in ticettJrnnTl3CCnnds cir ttrcirrwl ilcgrxs Z2°Cctfif=rcation:
{id wcli'9Kt4,+stie-laillpr ds s�ttt3C11
l� W t ..¢/�wi�-:c. 8/15/2021
rS.t. afCerti Well Coaftnctar late.
6.Lc are!the well(&): EPennanent or oTemporary Agning this�flmttr,t herrkr rr 0j6d thr wr*s{was(!nett)tvmtimeted a?ftveurlimee
uvrh•!4�f Nt",AGlJIC'.0l�or d sd Nf'AC r12C.42(ttt Ni'rd Cor�rner�vltir Srnr;darePs nrtd dani a
7.Tv this*r+epair£b an idist ng wcii: Yes or KNo r'v&6,fthif nr,r nl)errs d+rma p»n•i*d to ik,,wrfd mvnrr,
IfshisIs a re{u kfil!avr 0[;im rvelJ`€MWn(M0W dtrdortwtiddurMd OX010lar tote ttartare OftlIC
repair mrder;S21 remnr&6-srctiam or rut the hrxk alMis fnrat. 23.Site diagram or additional weh details:
Ywi may use tk bac'k of this page,:to pm%ide additional sttgl site details or well
S.Number of wells constructed: 1 Construction del.ails, You nia}also nttacb additionat pej*s if ft cessary.
For mddp1a lnfrcrkut or aem-waree s*ptr•irmfl;t NLV%*A rho sarttf corrs�urllaur,5va i�em
sn&rnitm�r farm: Sunk iTTAL 1NSTCICTION3
9.Totalwedt'deplit below land smriiacu 25, {ft,) 2aa. For All Wells- Siibinii this farm uithk.10 days of complcGon of avtiell
i�nramrrta�lrePltfiatrrJ{ctel+t§stf{ir�rnt(c..rirrrtc�2t7p`er?af2�ld7i�tt €rntSintGtiontolhcfottotcing;
10.Static water level below top of casings 15' tfr°) 1►i loon of Water Resqu roes,lnfirrmatiom f�xnees+ang Unit,
If sr+aiL�t k-M is a bow cdth g,awe"+ 16117 plait sertire C64 r,Ratefrlf.XC'2 76 99 44 1 7
11.Borehole diameter 8.25" f;e l 24b.1~°nr jobS11orf�'l+eticgNLV: let addition to sending the fort to live addrm,in
24a tibovle. also submit a copy of phis forth within 30 dim:& of c6ntpletioli of well
12,Well construct1on rMbod.AUGERS mIstraction to the follo8Y11ag_'
(i.e.soga:rotary.cable.dins:push etc.)
Division of Water Resources,lAdergmund In)eciion Control ProgTmiv.
FOR WATER SUPPLY WELLS ONLY: i636 M ail Service Center.Raie'W1.NC 27899-1636
I
13A Yield(gpm) vlcldla+atf of test 24r-For W;rtcr'Supply.1C inlcttutnl Wc1Rv
Also subd* one copy of this forni atitbfn.130 days of.eompletion of
131a.Disinfection h Amount- A%T1l construction to the cbarrtty hcalttt dcpaitmrnt of the crnrrttg tnc�rc
constructed.
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Pam,G%V-t R evisrd Augffit 201 t