GW1-2021-04164_Well Construction - GW1_20210827

WELL CONSTRUCTION RECORD For lrstanolUscONLY:
This forin can be used for sin&w mW inic%yells
1.Well Contractor informittloa:
Stefan Smith FROM ri IPITON
Nall Cordnictor Marne
3576A
NCNd1CoalmaorCcn1l1cslbhNnrt er i t)t1TER LEt1:i134 orit i�IsM'tic . 'OA: cable
FROM To Dr.AMEFm TiliCi4ti'r.S,9 MATERIAL
SAEDACCO Inc 0 fL 8, iL 2" i ta. SCH-40 PVC
Cemp.�srytfaar �1C1 CASt�t;aDR' IAfG- �, >.
PROM TO DU\iRTBR Tn1CA11PSS MAWRUL
2.1Ye11 Gnnsttvccl+tn Permit tl 70002914 th (I.
L o an4yr in N'W'Upetm or.Coumn,skim Vorimwe.r4efMn r r)
h. f1. in
3.Well Use(check well use):
Water Supply Well: PROM Ta WAtvnrtia r sm. I '017 y MATP.RlA1,
Mpiculttiml OMmmieipai/Rtblic 8 R. 23 ft 2" la .010 SCH-40 PVC
Motheniml(HcatJ1rq):oohing Supply) OResidentfal Water Supply(single) it. ft to
01ndusttiaif0 mmercial ORestdcr thmh Wi far Soppt (shared) .1. GRO
FROM TO MATMUL HMTLACt E T M£Ttl D A AM UNr
01friontion ft. ft.
Non-Water Supply Well: (14
mmonitorfn optco-mly
Injection W n. ti:
OAquifcrAccharge 1143loundiinterRetnedltttioll tS S 15
FROM TO I IM r IA1.
oa VMPIA Y;4ir�ir7NFrN ri
OAguirwStorageandRcvW OSOONBarrier 6 ft. 23 f1. SAND 20/30
OAquifgrTest OStorru atcrDlairr
IL ft,
OF—Triimcntai Tahnology OSallsidcncc t ontml I
D<afsilislNillion
itrfieet3 'aiw:c3iit
OGeotbemwl(Closed Leap) OTrom Priam Ta DES C TFROc WWI 6*M 1trwn*k
❑Geo(hemlal ftaflagXooling Return) Mel er in under421 Renlatlo: 0 ft. 8 (L Clayey' silt
8 ft. 23 2 Sandy silt
.4.Date Well(s)Completed: 8-4-21 Wd.I M#TMif-4
it, (L .,�
Sm.WfAI Location: IL It.
The Ardent Companies A. 16
lhteilif 10urwrNadoo Futility WN(srWplicable)
6500 S. Blvd, Charlotte , NC, 28217 R. h,
Plosical Address Cinaurd zipILRUIAM7
Mecklenburg 17304204 Temp well. Sanded and sealed w/ hydrated
C.aoay fs mdIdemiri muonwo.(PIN) bentonite
Sb.Latitude and Longitlsde)n t4egrc�lminutcslsceondsor decimal delIrecs: 22.C+ertlfcmtlt►n:
(if asoi$fktd,airrbdiloit Is s!dntkrd)
35.143720 X 80.877199 W 8/13/2021
Sibiul of �Wdlmrcrot Due
6.Is(arc)thewell(s): OPemanent or zTernporary
Br Ageing thit.fQm l tkr s+Wl(sl iwts(isrtr)eti+nstimtt[d in brootifmanr
n4th ISA NCAC 02C.0100 ar IM NCAC 02C.0200 tell Camnnr tan SmrAmds and Idle a
7.irr this a repair to an eaiating lied: OVa or i&rNn Capy'afthLf reratrl.txrs lk`4W pmiGdrAMrhr Yl'r'lltM76rr,
if Als Ir o reptdr,fill revAw*w uW1 eamrnwdos hifomwrton erwf ehp►aln the m11rre of ffw
„fir grader A?i rormorks serum or an d e bar&ofthis fr rt r. 23.Site diagram or additional k ell'detalls:
You map use the boa of this page to pm%idt additional well site details or well
S.Number of melds constructed: 1 construction details. You may also attach additional pages if tlecessaty.
For nruWrde,lnfei 4m m nm-tiweio jW,*%WLY OAILV+rdrb the war catrstrus•#en.iwr cm4
a bad it nme,ib?m SUBAi[ML INS7 UCTIONS
9.Total weltdepth below land surface: 23 (ft.) 24a. For Atl Wel)s; Subtidt this ford within 30 daS of completion of Aril
For multtple gear ho aft eep Ass(/ct*r0111(eranapls-3@200,trodmmr) construction to the folio iW
10.Static hater le r1 below top of easing 11 (D,) Division of Water Itesources.Information Proeessing Unit.
11 water hwr)h ob ar tit,ate"+" 1617 Mail Service Cei lrr.Raldoifi KC 276".1617
i
i
It.Borehole diameter 6" (la) 24b.Ur 1nMeS Wells ONLY: In addifion to sending ft form to the address in
24a abmv. also stllltltit a copy Of this form within 30 days of completion of well
M♦irdl corstroction Method:AIR construction to the following:
(Le.slider;rotor).embla dinx8 piesii cos~) Dhision of V1 ater Resoura Underground inJcclo»Contrtil Yrrigrlmnl,
FOR WATER SUPPLY WELLS ONLY- 1636 Mail Service Center.Ralft.11C 17699.1636
13s.Yield(Am) Method of teat: Zac For Water Sapplr$e 7njoctkni Welts:
Also submit One cop} of this form %robin 30 days of cornpletion of
13b.1)ieinfeciiantype; Amnnttt: well conoruction to the county hcAli department of the counh wheft
consmicted.
t '
Foam G%V-1 Nanh Carolina Dqwtsreid of€m1miwrM and tbntrat Resomms-Di%it n oftlralcr Rftoirers Rm-hed AiVA 2013