GW1-2021-04162_Well Construction - GW1_20210827

WI&L CONSTRUCTION RECORD For lmcrnnl Use ONLY:
nis;farm can be awd far sfe*or rrml(i*wells
1.Welt C,antrractor_Infotmsiion
34't►�A 1t:zo
Stefan Smith FROM orSeRrvrrott
Awl Cold Ud*t Name
3576A
NCWdCormacrorCcnilk9lonNtmaber S.D R Q otwmiNicasrd`n ttiiituTtif,R but able
FROM LT40
DfAtlrrTi;at THIGKNFM MATERIAL
SABDACCO Inc 0 (L ft. 2" fiL SCE-40 PVC
t:em�xtn Marne afi ATG OR 1DfG= cdtlerateltlosed •
FROM TO I DIANIUM I TMCKNTSS ItXRFAX
2:Well0nnstrmtinn Permit#: 70002914
f else all�pplirnb)r+crlf prrmfd(ie.Cramtp.S&er.Varin,rr.TI�Ab1 r1r•,1
3.Wdl.Use(checi wdl V.,wY
Water Supply Well: no." nlAt�rs n re l—OT �r ^ntrearc INATf N1A1;
DAgliculttnal QMimic paUPublic 4 n: I i 19 2• in O10 SCE-40 PVC
QGeotlwmwl(HeatingCooling Supply) QResidentiai Water Supply(single) la
Qlndusaial/Commercial QResidential Water Supply(shared) '-'FROM ROM-UT
TO 11fATifRtAt, L.AfPfAC1IMk1TarEillt)ll AMOI,Tr
Dlrii`.loan h. ft.
Non-Water Supply WC11: (L iL
mMonitorin Mccovvy
its citon Well: n•
QAquifer Recharge QGround%vtcr Remediation 39z. 1) A dZ
rs MTO ItINTITRIA1,
QAquiterStoragc end Recoveg QSaliniiy Barrier 2 n. 19 ft. SAND 20/30
QAgv fer7csr O$Wmmatcr Rni nagc
n. (t.
oevvimcnial Twinotov QSubsidowc Controi-
20DR1t1UNKia1t)t;~1011irclY:sllitlflblar"t�taeer3lf,ieeesra '-
OGaothcrmal(Closed Loop) oTtacer :PROT1 TO DPACR rnola Nbur,t,att .. v"Wt"ek "ek
13Geodennal 8 alit Remm) 00ther(explain under#21Remarks) 0 (L 8 to. Clayey, silt
8 n. 19 rL Sandy silt tide
4.Date Well(s)Completed: 8-4-21 WdIIDdTMW-2 fL n.
So.Well ltoeatinn: n. (L
The Ardent Companies fL fL t
Faca7a1Yq0m=Name Facfliw TVX Cif w0kable) :it
n, fa. ,a�,01��' •j p�
6500 S. Blvd, Charlotte , NC, 28217 rL fL
Pkvsiml Addrms C 1y,and Zip its 74
Mecklenburg 17304204 rb
emp well. Sanded and aealed w/ hydrated
Coua� Id Pam" omotiooNo,(PIN) entoaite
ft.Latihfdc and Longitude in degr,ccOmimtte s4ceonds or decimal degrees: 22.C ertifmotion:
(iraed(i d,wig lalnotg 6 814f'itiefd)
35.145338 N 80.877686 W C 8/13/2021
Sigmt or Vl+etiCotar Date
6.Is(ore)the hdi(s): s7Permanent or mTemporary Bp.sfydng Orb fmm I hark,err01h*the n*14s1 was(were)mmrtnaaled in amn dazrrr
ulth l U NCAC 02C.01M or 1 SA NCAC 0:C.02M W rU Chair?tWcm Sranalttrds and tetra
7.Le this a repair to an t sting well: ❑Yes or PUNo r1.1rr rqf rfik Rrvrd has berm pmv1drd m vier w ll4m-no r.
ff iAtlr lx a 4'fr rWf'fill4Mr krtPIM n'ril rvansrrucrhm#*raWfW Wd ne➢fohr,rhe Mran()f dw
re!puirsu�rrd?1 nmurds srrtiaro ar nn the biee'1:df rhfs farm. 23.Site diagram or additional well ddalla:__
You niay,use tine fuel;of this page to ptmide additional wdl site details or well
S.Nombtr of crabs constructed: 1 eorntmction debits. You may also attach additional pages if necessary.
For,r MPle 1flj t'rlat 4M mm--oww srW#.r urth ONLY"Ith fir am eonstrard 1,}ea can SC71�At[TTAi-iNSTCIC1gONC
sadwi tom farm
9.Total welt depth below lj d surface 19 mt.) 24a. For Ali Wdlu Submit M form within 30 daay$of completion of mvil
For hlplr wells list 011 phi(,fdlJjirrewferompf-4@200,am'201aN1) coo5miction to the follon ng:
10.Statlevater level below top of.essinr, 9.7 {R,) Division of Water Resources,Information Proteming Unit,
If wryer revel h dbove edtlag,om"+" 1617 Mail Service Center.Rattigh,NC 27699-1617
1t.Borehole diarnelet-6° (in.) 24b.Far injection Wells ONLY: In addition to sending the form-to the address in
24e above. also submit'a copy of this fort'within 30 dmis of completion of well
IL Well constntedon mdbod:AIR coilstauction to the following:
(Le.'vj*.rotary:dblt dircUpAh tic.)
Dblilon of Water Rem rces,Under'gronnd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Maio Service Center,Raletgh.NC 276994636
13a Ylidd(gpm) Method of test 24c.For Water SogI ft&fnjeaton'Webs:
Also submit one cop} of this fort within.30 daysofcompletionof
13h.Disinfection type: Amount:
well constnaction to the county hc4fth dcpoetmeit.or the county where
Constructed,
Fait G1V-1 Noah Comlim D.gwWMef F.av+mnnxN and Mono]Resomms—Division ofliraterR Rz%-Wcd AtViSt2011