GW1-2021-07699_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For Ireemol Use ONLY:
THs rem can be used(asingle or md(iple mnvls
1.Well Contractor Information:
U,I 'A R 7t) 4�
John Eiseaman FRON, T oF4fti1P7t0Y
�1eti Corrtnrelw Name ft, ft.
4439A h'
NC Well ConumorCcalfkationNnmber 13.0 CAfiTNt3 iNfi°as�itlrt ORI1Pti7tOfi}"Rcrtik::
mom L07
D1ADr1TErt TtRMffM A7LRIAi,
SAEDACCO Inc 0 (L (L1" in. SCE-40 PVC
CemOm�}Karr tN VR�1kM tGc -e
FROM I TO I DLOWTRR I THRIMTM 11MIAVM. AL
2.Wdl Con.#nzv0on PP.rmit#: 70002937 h. h. 1.
kite ar11,fflWirW,--Up"Wb(Le.Corrnry,Sane,taria-v,fj6[kn elf.J
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3.WeIVUse(elleck well use}: Al
Water Supply Well: FRD1" TO 1.01AMETRIt I SLOTSPT, lrl"C"r,% MATRRIA1,.
DAg)frcultutal 0municipil, lic 7 R. 22 h, 1° 1n .010 SCH-40 PVC
DGeothemai(TTcating(CooiingSuppty) DResidential Water Suppiy,(single) h.
Dindustrinucommetriai DResidential Water Supply(shared)
FRost Ta xxinnul ] MV]ACEMEWXT OD&M40W
Dint tion
Non-Water Supply Well:
h. n.
mmonitorigo
Dltecom
TD—Ron Well: (L
L7AgrcifrrRecharga D(3romtltm�itcrltemfdiation t =S lf,RA,
FROM MATRRtAL rgdin A •rr�'T1H. au
DAliltiler Slat gr find RCCOtvq MalinitV 13anict 5 h. 22 ft.. FILTER SAND #2
DApoifer'fcst Wtomm-atcr muringr
DExperimcntal Tacchnotogy Mu ideace Control h h
20.DRIfU2 G-Lola ettiictiadditlmat4rietta'Hhc ml
OGeodiet11al(Closed Loop) DTmcer FROM To DESCRtM01,;c*W.RuVni *WF4Ck tim fro Nc
❑Geothe3mal aft Cook! Return 130ther(explain under 021 Remmks)
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4.1)3teWell(S)Completed; 10-21-21 WdiID#TMK-4
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Sa.Well Location: tr. tL
South Boulevard Assemblage
Fkili WMwwrNa=- Fi lj W 1Dk(if appiivible)
fG A.
4001 South Blvd., Charlotte, NC, 28209 p h
Mecklenburg 1" temporary well
Chew. Pamdtdentolelmonwo.(Pill)
VnInAllupi PR
5b.l.attitade and Longitude in dcgre stmimltestsecandsor decimal degrees: 22.Certification: orFssING uNr
(it mull Aetd;we h0oug is SaMe4ctd)
N W' �. �''`✓ ' 10/24/2021
signawR orioi
i S1�v orG- �" D9rC
fi.ls(lrc)rite ssr11(s): i1T+esmetteut or OTemporary x'Cr v ' .` 9 c�+nrr;�rred,w aeronfAnoe
11
ul-OgWrhtft�NCAG�C.�.+��Y:"':trigMt t1T�Pwell COM(irerORslZrandardsonuon6
7.Ix this a repair to an editing well: D'Yes or O Nq ter of fhG mrwd!errs brr+n pmi f to tl+e a rA rmv�;r.
tf.eels h a rvpdfe.,f 11 mr bw m tomxrtion mad mpfahi the rrarave of the
repairwder62)nmwrkr xrction or on d„•nook of tMs farm. 23.Site diagram or additional well details:
You nW use the Hack of this page to promiide additional wril site details or well
8.N a mbe r of~sells constructed: 1 eonstluction details. You tray also attach additional pages if necessary.
For rrtWple ld}trdr3or Diann-rMaver sWply tiWk ONLY tend.rue mme oonspvwdm,pour Care
a wtarar fama. SUBNIMAL INS' TU(T(ONS
9.Total`well depth below land surface: 22 (11,) 24a.For A Wtilat Submit dtis form uithin 30 days of complexion of well
Far,reftWe wtUs list all*p&v Ifd J rmi(exoVte-MM'mid?@ IM) Co wmction to the Waning:
10.Brunie water lemtl below mp of ras(ngw (R.}
Division of Water Rrsourm,Information Proftsft Unit,
If+rvirer fewrf It ohmic cad4jr,.cur + 1617 Apart Semite Center,RaiciiFh,1VC 276094617
11.Borehole diameter.2.25 (in.) 24b.Ur.Ink&g IM ONLY. In addition to serldintg the form to time address in
24a abve, also submit a copy of this form Within 10 days of completion of smell
tL V`dl rom4rPetle"msabod:DPT construction to the fallowiuig:
(Le.auM.romq•,able,diurcjxWL etc.)
Dlr'Lvion of Water Resources.ITndrrground Injection Contmil Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24e-For Water Suaw'&[Weatm►Wells.
Also submit one cop} of this forth trithin 30 days ofconmptdionof
13b.Ilislnfcction ty-pu Amount: mse8 construction to the comity health dcpamm# of the cou",where
constructed.
Fenn GUI-t North Cambna DelmuMxat of Emrimruocm ud Natural Rewtms-D'n*ioa of ltrote Remum Revised Axe&2,013
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