GW1-2021-05393_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD for rrftnt Liu dnX
M5tuma cart boawd(or sfticormullipkuvils
1.Wdl Conindor tufarntatleir
Stefan Smith VROM I TO I D truck,'
A141 cool aeenr N-Atm
ft. It.
3576A OCT 1 3 2021 a Htttl rdr
NC Wdl CortwdorCenilkxtion �Niurd i• tint 'OR;iili i.K �ICYb
Rth
TO DIAMETER T"nTA`TSS MATERIA7,
SABDACCO Inc Infort„atR{�fOC@SSIRt� Unit 25 n. 1" in. SCE-40 PVC
c 696ki N R' INGA ttensailtitiieda ;-
ee+rftXtsry`Nam
TO DlAhtt?TBit Tr1Ci0\RSS 1lrA7ERIAL
2.Weil Gonstrnd hm Permlk fi: 50000079 it.
Lis ail applir%Wr wril pemtin f1-r.Cmmv.Smzr.Variamre.Ifibe art err.)
fi. iA.
3.Wdl Use Obeck;well usc}: t
GR
Water Supply Wdl: trn0M 'm TAMKTrR SHOT sx, VIRC NMS .MA"MIAt;
Oftf cultural 0Municipal/ftlic 25 (L 35 fti 1° 11L .010 SCE-40 PVC
Qtieotbenurai(Heating/Cooling Supply) olkesidenilal Water supply(single)
F.
pindustriatlCom F
merciai DRosidentiM Water Supply(sbated) FROM
Oo7'- . -
FROM TO MAT$ IAt:R '�TTtAC1;111M MFSRIOD QAMOU'NT
131rri tson f4 ft.
Non-Water Supply Well: (L
zManitorin Dltetea�
In eeglnn Yclt: h. ft.
A uifer ta0ranndrvaterRcmediation :S'. V A sue
- ��'�'
3 � RI1,i.A N{# fL
im plA YTMb DFH M tn TATR
0Agnfr.StOMgadRecovery WalintyBarricr 35 i, SAND #223 ft
OAcpt terTcsl ❑Stornm7sr Antiosgc fl
❑Expertmenial Tachnolog ❑SobsidenCm*Tvl 01
nN�eF°ati�fiiadat:6l+cttsit°
O10,00detmal(Closed Loop) OTWeer :FROM TO I DH"TPiTOV our AswnrSa ysLL'rncrt e e
oGeot wanal(HeadfWiCo2ii Return) 00iher(etplain under#21 Retnwiis) 0 (t. 22 IL silt
22 M 35 ft, Sandy Silt
4.Date Weft)Conlpined! 8/30/21 WdTM#B-1
ft. ft.
Sa.Well Location: (L (L
Shell Oil Products, US ft h.
Fes:ilkX1um-r Name Fxi1W IDk(if sppticabW
ft, ft.
101 W. Woodlawn Rd., Charlotte, NC, 28217
ft-sual Adtims.City.and Zip .31i Alt
Mecklenburg 16903203 Temp well for groundwater grab sample.
Cunrr PrtKcttderA tlaat)oatdo,(NN)
Sb.l atihtdc and i tingtt do in ftmeshninutes/sceonds or decimal degtses: 2L Certification:
(ttxtit,ilt K we boott is sidncicta)
35.1 N 80.884032 W _ �1_1_wc
"" 9/28/2021
Sibmt ¢ofCt.. inta:tor Date
6.Is(are)the well(s): t3Permanent or MTe mporary By sfgaing Air tapir I hereby r*M#MAP Mr urfl{s)was(rtrnrl wwrnFeled to&VOMmmr
w0 l%1VCAC'02C.01M or 1 fit NCACOZC.OZM tWO Cwwrr Wiw Smn*wds and char a
7.Is this a repair to an a cisting well: f 31'4c or 0110 inWr oftUr rrronf hat hrm prodded to stw,tell4wwrr.
ff Aij h o rep!dr fiH ow,k artsrt uwV eoauruevhnt Br rrm4anand expktin rAe wmfe of r1w
rrpoir wider t21 rMorks Arrsh*or xm the hock of ahb/arot. 23.Site diagram or additional w'di dclails:
You nmy use the back of this page',to pTm'ide additional well site details or well
8.Number of wells constructed: 1 construction details. You may:also titlaeh additional pages if txcessary.
For sWilpfe Injecrlmm,nit-wartr taQ4*kAb ONLY"ItA&sffmr constrw4o r.v"Cart
aa(xiut aw forum. SURNIMAL i11TSTUCTIONS
9.Total wdl depth below land smrfaee: 35 ((l,) 24a. Por A Wtllm Submit this;fann within 30 days of coinpletion of well
Forma Nple wdtls'14t 0 deftAs if diffr►em(emtttyte-30-ZW'aM 2010QY) Construction to the.fononins:
10.Static water level below top elf easing: 30 M) Division of Water Resourics.Information pro ewng Unit,
1JnaTrr Morel it otiaty rdsiag,rase 's" 1617 Mail Service Center.Raleigh,NC 276"-1617
11.Borehole diameter:2.25° (itz) 24b.gnr jRWWUp Wale ONLY: 13n addition to sending the form to the address in
24a'abo%w- also submit a copy of this form Within 30 days of completion of Well
12.Wedl vortstrnetion mahod: DPT construction to the follomvinMg
(i.e.mcgcr.r=q.cable,ducat puslt etc)
Division of Water Resources.underground Injeeflon Control Program.
FOR WATER SUPPLYWlfld S ONLY: 1636 Mail Service Center,Ralelgh.NC I76"-1636
13S.Yield($pm) Method of test: For Water Sapptu&Iploctfort Wells
Also Submit one Cop} of this forte Witbin 30 days ofconlpletionof
13b.Distufedinn npe Amount: ncil Construction to the courtly hc�hh department of the county wh=
constructed.
Farm GAF-t North Cmlins Dcpmtr=l of Emimmont and i+k uuW Resoarm-Divaion of Water Resom s Rn iwd Atagt6t 2013