GW1-2021-05382_Well Construction - GW1_20211013

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' WALL CONSTRUCTION RECORDorttrr�luset�rll�: C
'then fo m cuo be for Mn&or mW l ipk suds
1.Wdl Contractor Information:
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Stefan Smith VROM Oi�C.i INTO.
NtsllCo*t wNITM Q. R.
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1 �� S outtefi tHu=�tnr�,y�t�nt.
3576A re),�
NC WdicalmuctOtConifxsl.i WMMbcr vim' 01tltstl!Tf:R. 1Dnb
SAEDACCO Inc Ery� Q4J 0 FROM TO ft, 20 ft. 1°AMETKARIs. SCE 0 PV7FRrAi.
Cafivis}•Nam
t+TttOlt YNG'_ art?irisEOa :. ..;
FROM To OVOTETM I TitK'kMTSS I MAT MR AL
2.1ye[iCan#MClion permit#: 50000079 ft. ft.
fin 411 avplimme wrilpermrts(Le.Ccarary,Ralf.Variance.1f fe fn rt...,) th
3.Well Use tcheckwcltasc);
z�.
-Witter.Sup)th':Well: FROM TO _ nIAMR7i:R V Ov ►>ar Tttleucm MATP.iuA1_.
DAgriatlttiml O2vkmicipaUPitblic 20 R. 25 ft. 1° 11% 010 SCli-40 PVC
uGeott►imnai(Heating/Cooling Supply) Mesiderdal Water SupplY fsinglc) ft. 1G11
is
171ndustriaFOunimetrial DResidentialWater Supply
t>pph'(shared} FROM. TO MATHRUL 00t,A &AMOUNT
_
Dtrri ion ft. f4
Non Water Supply Well: n. tr,
®Moititglin D12txos
In jettlalp Well: rl. fe.
pAguifct Recbasge 00foundwater Remcdiation
DAgi MT stotagc and R *'%V y OS9lm1 Hamct sew ,► _ i'tF n VR M' A bU
18 R. 25 rb SAND #2
DAguifrr1rest CiStornm-atcrDmi ltlge %
DF:q er n=ftl7`«linoio,8t 0Subsi4ence Control
TO atscR
DC,toihet�l(Closed aft:=n�ttrrtat� stitieliDRSCIt h@t'trceiii C"
Laap} t7Ttace� ;FRori rr°riaN abr,at. snR+mesd ta.►
DGtodomait(Ha ti p oii Retunl) ❑Other(00hin under d21 Renwh) 0 (t. 14 M silt
14 ft. 25 It, Sandy silt
4.Date Well($)Comitlelede 9/1/21 'Well JD#B-12
ft, fe:
54.We"Location: (L h.
Shell Oil Products, US rt. ri.
Finail}rCArmrName Facility lDit(ifappiictible) %
101 W. iroodlawn Rd., Charlotte, NC, 28217
Plat-Wal Adda:ss Cjiy.and Zip 37 RIsAtARKS :, 3'
Mecklenburg 16903203 Temp well for groundwater grab sample.
Camp• farce!IdWi icados No,(PN,)
.'tb.l atlitrdc.and Liongitadc in degmeshnimitc0sectinds or decimal degnx 22.Ccrt4ttcatioa:
(ttwell flekir mre lath is Wilekid)
35.178722 N 80.884078 W 9/28/2021
SiPmd of V11r1iC.,.=tor Datc
6.is(am)the well(s): 11Permanent or ZTemporary 4 s gHins Ah form 1 hereby errdfv rhat:rhr µribs)wra(near)w atnmted in ai vnAorre
xtrh 15A NCAC 02C.&M or.7SA NCAC 02C.0200 WWI ConarrinMon Srm&*w*mid Ow a
7.Is this a repair to in existing well: DYcS or ®No ropy of this rmurlhas bretu pmr*4 in Or antii tmvrr►.
if Aria is a awdr.flil out AWK''N well rnv►.rt M(m;worvaof on and fVfdbt r€tr wrare of an,
reprlra lrrb3l rrraretka,rertlarhgran rbr burl of rhls farm 23.Slt+e dhWam oradditlonat wdl details:
YOU may use ft back of this page tb pmt de additional i%vil site details or well
ti.Nomberef wells constructed: 1 consimcdon details: You ma+also atlach-additionail pages itneeessary.
Fo neeilmi a am-ftwrr Arplr weds ONLY nVfi the same t onstsaatFao.;soy cansubanftmefo GBBbitTTA1.TNC7MC170N$
9.Total well.depth below land surrat 2 5 ((t,) 24% For All Well Submit this form within 30 dan•s of oompiction of well
For lfi$r wrflr ilsr all dnnks{,fdPrem(rrmrofte--30700'seed 2@1&T) comtniction to the.fgito►tting;
10.Stolle waterline)below top of caslaW 19 ((L) Divhh)n of Water Recoui' lnforsnstiion PnoMiing tlnft.
tf 4wev k vt is above evthig.suer..;^ 1617 Man Service Cesiter,Raitiglb NC 27699-1617
11.Borehole dismt to 2.25 24b.Ur inkW22 Wefts ONLY: 16 addition to sending the form to the address in
24a above. also submit a copy of this,font within 30 dm•s of completion of wtil
I L Wcll eonsti action 010hod: DPT CO]WA Clit►n to he ft►llowing:
(Le.aript rotary.cable,ditia posts cic.)
Dhislon of WaterResources.Underground Injection ControlDtogmm*
FOR.WATER SUPPLY WELLS ONLY: 1636 MAD Senior Center,Raiekb.NC 27699-1636
f3a.Yidd(gpm) Method of test 24c for Witter 5apptn 8rin�ection Wow
Also submit one cop} of this form NAthin 30 fts of completion of
13b.Disinfection tJVc Amount: well consiniction to the county hea#h department.of the couudy,whew
consttncted. f
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Farm G%V•t North Camlim Depmtim t of Em•immncm and Wmtal Resourocs-Dhision of Wsicr Rest Revised At.CuSt 20l3

October 7,2021
Information Management
Division of Water Quality
1617 Mail Service Center
Raleigh,-NC 27699-1617
Subject: Well Construction/Abandonment Records
Dear Information Management:
Enclosed are well construction/abandonment records for the following locations:
Location Job# Date .
101 W Woodlawn Road;Charlotte,NC 13750 09/28/2021
1315 Outlet Center Drive; Smithfield,NC 13760 09/19/2021
3620 Atlantic Avenue;Raleigh,NC 13765 09/13/2021
Sincerely,
Karen Byer
SAEDACCO, Inc.
Enclosure(s)
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9088 Northfield Dr. ♦ 'Fort Mill,SG 29707 ♦ www.saedacco.com ♦ [phone] ♦ Phone (803)548'2180 ♦ Fax [phone]
South Atlantic Environmental.Drilling and Construction Co.
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