GW1-2021-05391_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD for lrtm)UsaONLY:
nth farm can be ostd.rar sing)or mWtipk%ells
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1.Well Grncrrector lltfarn)atton: � ;
i4.'W'21,
Stefan Smith R5,4DUM,
Ckir"O,
OVdtCr3ntsadorl�tnc j 3 ��-3576ANGWc11CoiVmctotCcnifical.ionNorr�cr t p� cC�1pt� G\Ctp ' �J 5 � ft. 1s4ntrrrR TFUCKWFM is. SCE-40 av�rAa.SABDACCO Inc
Potnfrts�}►�atrr1NOV 1l8INTO DtAttr£T6R TrttCKh'F.SS MAIF.RIAL
2.WeilCrinsttustionPermit#: 50000079 ft. 4
liH elk 4WHr"Nr WWPeM03 ttr.County,Saar,Vnrinwe.Ij*dCn etr.) K
R> th
3.Wdl.l3sc(check well use): 7
n ,
Water$lrppla Well: ARAM TO litA6tRTFR S►.AT t7E ?Hr ,. . #tAT ItIAta.
CSAgrittthtrntl Mnniapvgllf4tblic i5 & 25 fl, 1e ln• .010 SCH-40 PVC
DGeothermal(Heatityl/Conling Supply) DResidential water supply(single) rt;
DindustitalICommercial DResidential Water Supply(stared) aou olYr e
YROM To MAT61 UL "T►ACVAM-T 9FMC D A AMOUNT
01nigntion 0. fr:
Non-Water supply Wdl:
ft. ft.
mlvlonitorip DRecov •
Injection Well: tt. ft.
DAguiferReciarge 00roundwotaRemcdiation 1104 AN t.
A etch Stompand Recst+c pSatinin'BorderrRoM' �A rAr, t�vrr.A lM, Mrtrrr e"
13 ft, 25 fl. BAND #2
0Agx0fcr res1 AStommgtcr thaimgc
0Exp rimcntal Tcchnology Q$ubsirletrcc Control R,
OR�xn�lrc attreti: t ab��t;r:� .
oGeo hen al(Closed Loop) oTrac er "OM TO nesrRivrto resl7r.krMx�+a,RtrncR tee.
oGdotfiertwl(HadrwJCD Return) 00ther( ` under#21Retnadls)J 0 fL 1s fr. silt
18 ft 25 % Sandy silt
4.Date WOO)Completed: 8/31/21 WdIM#B-4
tt, fY
Sa.Well Ucatlon: (L (L
Shell Oil Products, US ft. R.
FwilityMix,mr Name ftHity IDN(if spp5:dblel
rw ft.
101 W. Woodlawn Rd. Charlotte, NC 28217 Mecklenbur, p,
Charlotte, NC, 28217 PlgiicsiAddtes 0w.andZip 2t ft194t
Mecklenburg 16903203 Temp well for groundwater grab sample.
t D"My PArcd loctair anion No.(NN)
Sh.L401tude and t ongftndc in dcgrccs/mimrtes/setonds or decluml dcgrew. 2L Ctrorrratlon:
(ifakil field,ante bOong Is sirt(ltktt)
35.178875 A` 80.883945 W 9/28/2021
isGc. Wti)Coimactor Dave
6.h(pre)the wcil(s): lVermaneat or zTemporary &siarnn't i42r,fm*l hereby twrrifv thal ow"withal wof t»e„ri rowinrated in orrordwntr
u4rh l SAA`CAC ox xiAft or isA ivcAC ac,0 w Well Cturrtim on StarAirds end An
7.L this repair to an existing well: OYcc or MNo copy ofthir noel baabern prai*Ard to she" 1 o vwr.
tf Ats 4 rt ovpwr.,till out kwmvi xwll C6W"urtfao#tifrur wrion chat rs kbt rho MWre of the
rrpair wider#21 remorka sret an or on the bark ofthir form. 23,Site dinrarn or additional well details:
You may use(be back of this page ito;pm%ide additional well site deWls or well
S.Numberof hells eortstmeted: 1 constnrctiondetaffs, You tmrs aLso anode udditlabM pages if necessary.
For multtpielnjeedwj.er nan-uwier jW*weds ONLY nfth the atnne eonsgarctlart,yor can $DBAt�� +.1 �1 sebm it'aru form. -
NS
9.Total wdtdepth below land surface: 25 ((y,) 24a. For Atl Wells: Subtmt WsIorin within 30 days of completion of yell
Far nliiplr k ells?istntl deprAu 1f dfJre►em leatxta�ly 14P2111t`anul7�1i/j tonsintdion to the-foilonii
10.Statie.+vater let'ei helots'top of easing: {R,j Division of Water R sourees,Infar roation Pnoceson Unit,
lfnater hwl is at ove eatlras,,ante"+" 1617 A'fail Service Ciater,Raleigh,KC 27699-1617
11.Borehole diameter:2.25 a (; ) tab.Egr lohxilon=is ONLY:In addition to sending the form to the address in
24aabove, also submit a oopy of this form within 30 days of completion of~nett
12.Well construction method: DPT constniction to the tbllowhig:
tic mqw.robsy,cWt diycd past etc.) i
Dh'islon of Water R.esourecs.!Dlnderipound fnjwdcli Control Progratn,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centex,Raleigh.NC 276994636
p
13a.Vicki(gpm) Method of test 24c.For WaterSapp1X&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:, Aarnunt: well construction to the cwmly health dcpartrnatt of the COrinh wbCTt
constructed.
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Farm GW-t NmM Carolina Dqnm=l of Fcnitommmt and Manual Rmwas-Dh*lon of Warr Reshtrces Retied Attest 2013