GW1-2021-05386_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD >�orinn dusxtsxrv;
7M fam cm be used for sik*or mWtiple mils
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1.Well Contractor information: ,
Stefan Smith rR M DMCRtPrtrrY
1V3576A
dl Contractor i tarns
�C� 1 �}��� s4.oaat.+ xrJ arirhsklahsedsiiefl OR :
NcWdIcamctorceflirlizinNurber FROM. TO DTA. 7ntGKiViSS MAWMIAi.
SASDACCO Inc 3tv^� t $Glt-� 0 11. 13 (L 1° la. SCE-40 PVC
r' it, NG R iNG; 1�eriai9tlesFd!"
(an>tKtl�y`Niale FROM TO DTAMP.TSk Ti11CKAFSS MA)ERiAL
2.Wr3tConstrntdmPerfnitit: 50000079 ti. fl.
l ut al)oppUr able volt prrmlts(i e.Cmnty,Stair•Vnr owe.I40Cdcn rrr.)
tt. p. iah.
3.Wdl,Use(ctheck.vrell use)' t7
Water SupplyWdl: FIrAM "M DIA=91t T nx TInC.iT MS MATP,RW
®Agriatlhlr8l l.lMimiapall!'ubiic 13 (L 23 fh 1° ins 010 SCE-40 PVC
OGeotl►ermal(lieatin�otfling Sttppiy) @Residential Water Sttpp>y{single) A. rt. la
OlndttS[rial/COnlnktriai L7Residential Water:Supply(StNned)
cRolir
FROM I TO ,MATERW. 09tA IriTMBfltOD@AMOttNT
O ig lion fi. rL
Non:Water Supply Well:
®Monhorin l�R4r0�
Injection etl: h. . fit
0Ailu'rfer111ccilatge 00roundvmlerRemedlation rR A ar
OAguft Storage and RccovvV i7SalinityBarrier TO L panriar%h �srrinrre f n
11 IL 23 ft. SAND #2
❑AquiferIlest ❑S(ommaln I)Wtogc
Mixtimcntai Trchnetogy 0Subsidcnce Contmt R. ft.
29 RnA NG tfeM re Biitd*i11 �edF<3fi+cccsta n.
ocleothenrmi(Closed Loop) OTrdcer ,FROM ITO DT�LTttPrI01 4wTar.hprle _ avanck d�aele.
OGeothennal(Reati oli Remm) odder at under#21 Remafs) 0 ll. 18 (1, Silt
18 th 23 (i. Sandy silt
3.Date Wetl{s)Completed: 8/31/21 Wdl ID#B-8
ft, ft.
5r.Weil Location: tt. f,
Shell Oil Products, US ft. (t.
Fac17iiy;K)nncr Name Facility TDa Cif apptimbli)
101 W. Woodlawn Rd., Charlotte,, NC, 28217 R, 04
Physical Address Ciq.and Zip 2t
Mecklenburg 16903203 Temp well for groundwater grab sample.
C.rmssnr l�Art;ttldrrt13r6GpfiSti No,(Mtd)
Sb.Latimite and tungitodc in dcgree stminutc0sceonds or decimal degriecsr 22.Certifrcatnn:
of O$Il etd,ow talilor@ is sldnekm)
35.178765 N 80.884073 W 9/28/2021
�iSmt afC .. WettConttactor Date
6.is(Yrc)tbt)t7ell(s3): t7Pertlranem at zTemporary ll r�fgnins Mh fbrm.1 hereby nrrdf}that Aw>nellls)*ft(whir)rowtftwed bo-earths er
04.15A AFC4C 03C.t)1W or I SA NCAC 02C.02%)W eU Cbmrrrkem Smadtlyds and dig a
7.Is this a repair to an o11l.Sting weW 01a or RING raprojfh£r:re+r�rnd bus l�reia pnn&ied tndr#rot mtmr.
ll thls is la rrpMr,,f£t7 nut krrm+n>.mU pro+artrtrcttaa)itfotrrxetton:�rd rxyhalrr Liar tts?fNrr rf the-
reMirwderd277 r maris srctian Bran the hoot:qff ibis form: 23.Site diagram or additional eelldetalls:
You mWAtse the bast;of this page to provide additional well site details or well
S.Numberef avib constructed: 1 construction details.You may also attach additionalpagta if necessi n°.
For tmWpfe Jn/eedon or nrM-revsrer jWpJ}uW1s OA'CY"Ith dnf some soashWffmn,vau cmT
nibenh ano form S1lBCNMAL INsT[)moNs
9.Total well depth below land surface: 23 {n,) 2Aa. ii1or AIi Wells: Subic it (his Arm within 30 dpy's of completion of,,tell
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for,nib4ptrwUsHaafl;trpdaffdifferrr;(eraple,-3@200'amdlolay) constriction to the following:
10.static waterierel below top of easing {g.) Division of Water Resources,Information Processing knit,
If Heuer kvrl iraben c nalnd wx"+" 1617 Mail Sen iec Center.RaIcW ts1C27649-1617
t i.so diameter:2.25° On.) 2I6.Far tnieetion Wells Oi`Ii.Y: Ilto addition t0 sending the fame to the addns in
24o above. also submit 7a oolw of_this fort within 30 days of connrietion of well
12,Well cDtlsti7Tctlon widbvd; DPT eonatuction to the following!
(Le.aim:mtaryy,cabie iiimx pm li.dc.)
Division of Water Rcsanrccs.Uh derVMuml Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 hail Service Cinter.Raldgh,NC 276994636
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134L Vicki(gpm) Method oftest; Ur-For WaterSRp&&tnleetlni lilts:
Also submit one cols} of tots forth within 30 days ofcotuptetionof
13n.Disinfection type: Amount: well constriction to the cowry health depvrima, of the comic whore
constructed.
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