GW1-2021-04165_Well Construction - GW1_20210827

WELT.CONSTRUCTION RECORD for Ift m)Use ONLY:
This.rarmco be ascd rar srrgh ai maltipk%vus
1.Well ContrworinfortnotIon:
tag,M`A'irite
Stefan Smith FROM TO 1 Dr4MI1,1101V
1ti141 Co.IsttaciOT(`lank
I
3576A
NC.WC11ContoctorCenifewllmNamber CI[t7FR fiTNOAorrineMir:lxed t)B1.1N1:R. 's Beall
FROM I To DTAI.WVM TNrCiSTSs MATERIAL
SAEDACCO Inc 0 (L 15 (L 2" ie. SCH-40 PVC
Cori pviy Naarc td:t s (:iCtR" $ "' isarmad ct6teda '
FROM I TO I DtA:MEM I Ttt M''i.SC I MAIERLIL
2.1*V4lCon.0rvv0mPermit#!: 70002914 fL R.
lrct 01)awirnhtr wrtlprMits 0-r_C'aoovp,Stan,Variance,l?emari Mr.)
3.W41 Use(cheek well use):
Water Supph,Wdl FRO Uurrrr)ta izvsirz 7tTitacRa MATaR.Lnt.
of glicttltntal t2MnnicipmlFl)ttbiiC 15 R. 30 & 2" In. .010 SCE-40 PVC
ClG of wrmal(fieatin&'Cooling"Supph) ®Resideutial Water Supply(singe) B B`
OI1ldustriaUConvrretriai DR.esidential Water SWpty(stated) ill t3RiDU1
FROM TO MATERIAL 091ACE.MLNTMEIIIOD&AMOUNT
13hti tion (l. (L N/A
Non-Water Supply Well:
®Afi0711t9Ti oRecm A.
f e on Well: %
❑Aquftltccharge 00rounduatet Remodiation .>
0A(lvifcrStomgc and ReCAnvq OSalinhy Border FROM r atar. . riw , rat t-rt D.
13 R. 30 ft. Saud 20/30
OAgttiferTcst t3stornmmter'Drain.1RC
OExpeTimrntRl fcchnotr> QSubsidencc Control
o,,: Rtr,�rltlx)t)(►t�i►irct��ealtrAr,e_ tree�sir�cce�
❑Geothenual(Closed Loop) 0Tr2cer .FROM To orscntr`ratlx tolut.hMsia xttMre4 ebn�«sr
oGemisetnnal ea' Return) o0lher(explain wider#21Rentatfis) 0 h, 7 tL Clayey`silt F--:°e
7 ft. 19 ft. Silt .'q ,�'
d.DoteWell(1)COmpiettd: 8-4-21 WdII1117TMtP-5 19 (L 30 (t. Sandy silt
ft.Well Location: n, ft.
The Ardent Companies n. (L r r�-r,!�
Fwi1 q/t)u=Name Factligt9k(ifapptimble) M ft.
6500 S. Blvd, Charlotte NC, 28217
P10!iW AddmsL Ciq.and Zip 21:;ft
Mecklenburg 17304204 Temp well. Sanded and sealed w/ hydrated
Caaah, 1trcd I6emAW0000.(PTN) bentonite
5b.Latitude and 11- rngltitdc in degrecrAn nuteishmondsor decimal degrcrs: 22.Cer4i kAon:
(Itwon ltieM,we tAlong is sitinckra)
35.145012 N 80.876676 W 8/13/2021
SS W�C- t. D3W
6.Is(ore)the wdi(s): OPermanem or WTemporary By s r Wt Earn,I krebv tern%The)the wrll(s)rot(nor)ranrrarcred in mronimcr
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Comt msian StanAwda and that a
7.is this a repair to an existing well: oYes or ENly cotmefrhlx rrcoml hos brew provided to tfio++ 1t aw rr.
If Alt la 4 trpetr.pit ow env isra wzt1 rowmvlan lnfarr+ dM and rgrl0M rV Jwnyrr of the
rrywiranderA21 rcraar&r srrrian a►.ran the bark of this fart 23.Site diagram or additional ivellAttalb:
You may use the back of Ns page to provide additional well site details or bell
S.Knuiber of wells constmeted: 1 construction details. You mar also attach additional pages if twessaty_
For mhlple 1njmimj or mm-,4,&vr ripply weds ONIJ with dte wmr oonsprur#an,voa air
m6mir ane from. SUBMITTAL INSTUCTIONS
9.Total well depth beer land surface: 30 (It,) 24a. Fbr Atl Wells: Submit this t'ann within 30 dms of convWon of-nrll
For Awaltwe WHII lin all dep*1ltdi enw kxmrtpla,3@2 np'and 2@1 ) consmiction to the-foltoning:
10.Static q'ater!coat Ddow tap of casinpr 9.5 (B,) Division of Water Resotirtm Infonmation Prm sft Ilnh,
If Mlatrr hurt lT abritle fYlalaR:age"�" 1617 Mail Smite Center,Raleigh,NC 27699-1617
t 1.Borehole diameter:6° (in.) 24b.Far 111kolM Wells ONLY: to addition to sending the form to the address in
24aabove. also submit a copy of this form.ivititin 30 days of completion of util
12.Wdl construction:mobod.AIR Construction to the,wowirtg:
fix.wrer.tog*.cabicditoctpnXex.)
Division of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Se nice Center,Raleigh,NC 276991636
13a.Yidd gMTn) Method of teak Vic.For Water$anplc&Ipjacti n!Wdis:
Also submit one coff of this form %�*Wtn 30 daysafcompletionor
13b.DIsinkelion it pe Amount: 'ATtl construction to the comfy ha iith depornnar or the casrnty(chew:
constructed.
Form MV-1 Noah Cmollns Dsmmmrar of Emimn=w and(`lames!Resotms—Division of Water Re5um Ren wd A4a 201.1