GW1-2021-05390_Well Construction - GW1_20211013

WEL tCONSTRUCTION RECORD For lrftmatt/seoNiv;
'M s,fonn aatnbc emd for siTtIc or nedtiFlc V+ells
1.W011,Contractorintormation: �a ! �
Stefan Smith' /RQM D thr0�
well cortsmaorRanae j 1 3 2p � % R
3576A Ql, Unii ft, rL
to�e�;�n9 �s,o(rr (t.cAsngG nrvnrtll�nea�te as 1k.h
NGWe1lCcntmaorCani6oationNn>rber �tig5lp oCtiOnFROMI . I TO 11TAMr•TRR Tft1CKNKS9 MAIUJAL
SAEDACCO Inc 0 (L 14 (L 1° le. SCE-40 PVC
Comptin)-Nimr l6.lff iE1Z. R 2 t78 f►er+m�tlnsed ;
FROM DIAiI1tTRit TIHC'NTM MATERIAL
2.Vl'ril CAmOra�ion Permit fl: 50000079 (t, ft.
lutalaeq�fir4abdrxrflptrmhr{cc.Casrray,Smijr,Vnrinarr.Ir#eeO'arr Mr.) n. n. iR1.
3.'%Idl;13se(vboek mill ucc): T7:=S
WatcrSoplily Vlydi: R H1 TO 1 J)JA6tKMR I SLOTSIFF, I TUTCUNTM MATMIAT;
DAPicultterai Municipal/Public. 14 ft. 24 ft, 10 to .016 SCE-40 PVC
Ci()enthemeai(Heatif0tooling Supply) D Residential Water Suppb,(single) %
OEndusnial/ ornmercial DResidential Water SitppV(sleared) Fti:CRbi€lf
FROM TO MA HRTTIACBhtB�1T]Hl ttrOD fi AMODRr Non-Water Supply well:
(L (t
mvta nitori DRec'myry
I njectlor Well: ti
OAgidfcrRccharge DGroilndTrntev Rc nediattion
DAgmkr.Storage and RccovM Ds,9linhy Harder 1� �9 fh 24 (t, MATPPAASAND r #pl n' Mi rH n
0A("d(cr Test AStormuVer Dmitaagc
ClExpetdmcntal TcthnokV, MUtSidcncc Control
20.; RU"fiG1i0G !; l0 'rltfc9(a�ecasssr�
13Geothetmal(Closed Loop) D'7lraacer :FRoa1 TO DRSCRiP(Tor a►isr A.waea�daghnct4 n ere.
OG6oflm al(Reat%n r 'old Retum) DOtber in under#21 Renmks 0 (L 18 IL Silt
18 ft. 24 fL Sandy silt
4.1)atoWcll(s)Complcted3 8/31/21 WdIJDas-3
(L tL
5a.%led Location: h, (L
Shell Oil Products, US (!. fL
FacllkXl%—t=lame Fwil t5 IDN(if WhublO
R. tt.
101 W. Woodlawn Rd., Charlotte, NC, 28217
1'tgsiel Addn ss Ciq.BndZip
27t
Mecklenburg 16903203 Temp well for groundwater grab sample.
(ditw 1►AM61derattkationNo,(PIN
Sb.L*Imdc and Longitude in dcgrecOmIrmtestsmindsor decimal d.egmw. 22.Gcrtifxtit8nn:
(if tsrdt(lofd.eate L*bfe s srdllcicrct)
35.178863 N 80.883975 qlr 9/28/2021
Sr6ta41 of Wadi Cotor Date
6.b(are)The nell(s): aPermanent or oTemporary p,sl ' drir form,1>e_,,1, H(
"J� .fig ""J r•'Y.•'.(l��l(�J4`tlYllf.4)IttY'9(MTIl!j L1U/1PlllifllY(bf dKYYIIY(h7ltY'
with 15A ArCAC1J2C.9100 or IM k4C 02C;02MWrO Cbm"w-- cln Standards and chat a
7.Is this a r gialr to An existing well., OVO or MNli c�(rF+r(thlrmorrl has bren pra+vGkd roJhr artt onmr.
if ilrlJ la r+rJptda.fidll nat.krrmwa w�,(i tm�sr+txcrlanlr�amaarlwn ar�elpk�n rbr rarrrrr r4•rfic
rewbrdmderA21 rnaark aftft r Oran d r bart of edvlarm. 23.Site diagram orsdditional w6l detallls:
YOU the back,of this page',to prmjde additl*FW well site details or well
8.Number of bells co"nicted: 1 construction details, You may also(i Uch additional paps if necessary.
ForamNpleJrrJoislonoram-w4rerAWy,wUt ONLY i*frhdutmr7)somaon,vewiM
m6uutcaar form suBM1'1TAL iNSTUCTIONS
9.Totalwell depth below land surface: 24 (ft,) 2da. F'or All Wells: SAmit tttislfarm within 30 days of completion of well
pornrarldplrwrflcli3rretlrfa(uJlrlldl¢er tferirraFir ?�2()0'cnm'?�1tkY) constntctionto ft.followirW,
10.Static water level below tap of twiulr (i1,) Division of WaterResoarrt,Information P"tessing unit.
If%WI P Merl&&&tW 0JM'AS,W"a 1617 Maii Scrviec Gkntcr,Releigiy KC 2169 94617
1 t,11orehole diameter:2.25^ (In•1 24b.Fbr tnic W n Webs ONLY: in addition to sending the form to the address in
24a above,also submit a copy of this fomT within 30 days of conVietion of wdl
12.Well construction mtsbod:DPT construction to thelblloiAlig:
(i.e.aupr rdnTl;able,died posh axc.)
Division of Water Resoorees.VNeMraund Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Scr+'ioe cant e.Raleigit,NC im"-iat;
13a.Yield(gpm) Method of test 24r For Water SoRWE&tnleem.,Wcilc:
Also submit one cop} of this forth irithln 30 daps of completion of
13b.DUInfection hTw-, Amount: -,Yzll construction to the coamty hela th dgmnmcm of the county where
Constructed.
I
Furor GW-t Noah Camliut Dgwitn fl of Emitonnrm awl.Natu W Rmwws-,Dhidon of Metter Resdu s Rc%,bcd Atag o 2013