GW1-2021-05388_Well Construction - GW1_20211013

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WELL:CONSTRUCTION:RECORD For lmvnw Use ony:
'Mis farm can be oxd farsk*or multi*u4s
1.Well Contractor Ieiotm9lon: 7.
�
Stefan Smith
Avell co*acw trame 1—� �tti11 A. R. i
�P�g1113 fl. fL
3576A ilipi� ipn
t�cc� �J�Si.+oocl��t ctrrc� r ;:�tl 1. tl�.�
NG'WC11GOf1170CIDtCMti(6C i. IlVi171fbClFflOM im MADiY7FR TMCKNFM MAiEliIAi.
SABDACCO Inc 0 it, 15 IL 1n Is. SCE-40 PVC
t me 6`i CASING OR�1VB ;Nl " .a.
PROM TO DIA01r.TER I Trr1C1.MEM ".MAVVRML
2.Wall Constr uctign Permit#: 50000079 R. fL
Liu all sfgatirsidtr wrU permits llr:Gatuntp,Stmr,Vnriaarr,Igrscty'ai�:�
3,WddI Use(check rr dI a ). m-
Water Supply Wdl: FROM l.1HAMKTR1t ,l6 n'A ritT. RIB MATPRIAI._
C]Agll1tlljttlTdl D1i4tltfie(palli'tTlliic 15 fL 25 ft 1° 1% Old SCH-40 PVC
DGeotltelm l(Heafl%,VCooliag Supply) OResidenlial Water Stlppty(singie)
Dindt(St1ia1/CDMftWd31 DResidential Water Supply(shared)t1 CR01}T ..
FROM 70 MATPIUAL FAIPMa" MP.YT9ma& OLtvT
❑turi 'Hon R. fL
Non-Water Supply Well:
mmonitoripaQR�xo�
Injection well: fL
OAquiCerltech,•irglz CtOroundwntcrRatntdiatltm
rR M Ip IrAT,RU1i; rtMrr A , n'
OAqutlerStort p and Rccov ry QSalimty Harrier 13 ft 25 ft. SAND #2
DAg(tiferTkst ❑StomruatcrDrairmSc R. ft.
DF_,Wiimcntal Tcrhnolagy DStrbsiden=Control
3it�lfltJl:LiN'i3'f�Oti afloat,�iRtH'Ibei't�+tlisNnece�
❑Geothernml(Cloud hoop) oTraee r FROM TO OnCRTMON tembrbarftem mvrftkf3 58t
DGeotheimal(HeatiogCooling Retval) 00ther wcplainunder#21Atmaf4ts 0 6, is fL Silt
18 ft 25 ft. Sandy ,silt
4.Dat0Well(s)Compieted 8/31/21 Wd1ID#B-5
fL h
Sa.W011 Location:
Shell Oil Products, US fL ft
FxflkIelw=Na= Fetcilio-WN(irappii;wc)
fl. h.
101 W. Woodlawn Rd., Charlotte, NC, 28217 th it.
Pkskd Adlt m City.and ZAP 21 tiCM
Mecklenburg 16903203 Temp well for groundwater grab sample.
Coate lsAMd ldtrdifKA11004(PIN)
5b.14 t do and Longitude in dcgreeshninute 0sceonds or decimal degrom 22.Cc1irkation:
(lh e11461d,one boom is sleet crd)
35.178834 1\ 80.883919 W 9/28/2021
5i#Isst ofad;trdl Cottt®.k Date
6.Is(ere)the well(g): UPermutent or >ZTemporery
/fr sf8ntng his jarm,1 hereby tvrn%p thm tttr xrll(.t7 Kart(m tx)iirtrsstnmrd in atra+rderinr
wfirh 1 M NCAC 02C.0100 or 1 FA NCAC().C.OX0 Wen CARarrrALwm SRandarda cmd drat a
7.U this a repair to an ftistlog well.- oyes or MNo r'c�pne pl rhir rrcnnilsad(tr e+u pmrlrlyd torlee a,tr11 owvwr.
If ttals is a repair.flit ow b"WW'A well r0oaslmalm wamwiion oral rA rfain the M wre 4dw
repair wtder#21 re rnarb AtrAw or the hark of d1b farm. U Site diagram or additional weir detalt%:
You may use the back of this page to,pmide additional wiell site details or well
S.Numbe rot wells constructed: 1 construction details. You may also attach additional pages if necessan,.
for fflddrlelnfeCOMI&arm-none+jw' WWI ONLY"frh die WMrconshvedon.!rowcan
sebuutone,form. SjtBMfITALINS7 ACTIONS
9.Total well depth bebm land sarfmw 35 ((f,) 24a Por Art %Vel M Submit liens,fan"atiUrfu 30 dat•s of a otnpWon of saril
F0rJftW#Plr µ+let listanl de7rAT 9dor► it lenvtrt�-J@' #f1`and 7td 1iW) construction to the foiloning;
111.Static stater level below top of cssluZ 30 (D.) Division of Water Rcsonrtee,Information 1P.rovening Unit,
1f xatrr Mwl is fibo"trtafaa.um"+* 1617 Mall Scnioe Center,Ra1d0,NC.27t199-1611
It.Borehole diuneter:2.25^ (;n,) 24b.FoE JUkrtion Waite ONLY to addition to sending the fomi to the address in
2Iaabom also submit a copy of this form within 30 days of completion of%a
IL WellCorlstMetton method, DPT Construction to the folloeving:
(Le,mW.rmuy,cable died pash cm.)
Dtaislon of Water Rem Injection Control Program,
FOR WATER SUPPLY NM AS S ONLY: 1636 Mall Service Center,Raleo,NC 276"46M
13#.Yfcld(gpm) Method of test: lac For Water Sal►p!r.4E tn[eetion Wetin.
Also submit one off of this fond aitbin 30 ft-sofcoTtlpletionof
13b.Disinfwinn type Ammrnt: vmll construction to the county heiddt dgmmnc3u of the conno,n•hcn:
Constructed. i
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FotmGW 1 Noah Camlins Ifgtmttncnt of Env1mnmmd and NmwW Resoums-Dhislon of Nate+Reamtrm Revised AWM 2013