GW1-2021-00548_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD For lttsml use ONLY:
TM Wen can be nscd for sat C or MotiRk iMxlls
1.WOO Contractor Wottumion:
Brian hiving fROM DlLStRIP710H
W41 cooma tw Nand ft. ft.
4240-B
R. ft,
NC Well Comm iorConirkmionNutabrt ` .&&OUTER D nTymt giaednretRf t7Rl+JPi#3i 1F Ekablc
itiOM TO DINATF tiR THIt'KVFM MATERIAL
SAEDACCO Inc 0 fL 15 ft. 1" in. SCH-40 PVC
( tarts Name 6.1 ;4i1t7B1Pi Nbt
FROM TO I DtAttiww. I TTn['t.'Amm I MATERIAL
2,WdI Ct w0ruction Pertntl#". R. tt bt
J1st all trpptir"Ne tvrltpemct s Cite.CnrrnY,$mar,Irnrin e,(r ac$nrt rtr.t ft tL in
3.Well use(checkmll use)-
Water Supply Welh FROM ITO I VtAMVT9P'IrTpTst . tict(NIM MATMIA1,
Mgdcultntal 0 municipateAitblic 15 ft. 25 fR 1" feL .010 SCE-40 PVC
Mvothennat(iieatingfC ooli ng Supply) OResidentiul Meatet Supply{single) R. I ft. trt
OUtdtmsttrtltCAnmRtiercial OResidentia)Water Svpph(shamed)
>1:aiRptF1` A
@ROM 70 AIATBRiAt, TAtF MSrfttflt&AJMOL'i�t'
171tri tit7R ft. fG
i oa Water Sapply Well: f
(14
1gllY oxedorin 1 RCct3�
Injection Well: ft.
OAgpifer Recharge 00roundvmtcr Rctn diaiilm y ..
f'R AI. _ tAYltRtat. :At.'.'E]HF�TMF7ii
OAriuft StoT9Sc and Rc m+ely 13SRiinity Barrier 13 R, 25 ft, FILTER SAND #2
Mquifer Tcst OSIOMMater l7n gRgc R. ft,
OEVcAmcntmil Tcchnoitogy Q$ubsidenec Cou"I
tl«bRYf.11tic .rttacteaddtdbn ..;It�t9if� -
13CAothenual(Closed Loop) M acer FROM I TO ESCRIMON b*bV.&2t! trttimcri Re.
t7Geothetntal(Heati B&OHINReturn) OOther( lain under#21 Rematls) a. (L
R. fL
4.Date Well(s)Completed: 11/15/21 WdIID7TMw-2 ?r
s
x -
Sa.WO LAicattion:
h. tL ,
Charlotte-Mecklenburg Hospital Authority ll, fi, Q21
.a
racflityM%=rNatne Fmilily Wit(ifappiicable)
1000 Blythe Blvd., Charlotte, NC, 28203 ft. R,
Plt-*A Adtimsi Ow.and Zm
Mecklenburg Bentonite seal from 11-13'
Cbnstts P=d Idetlafkalion No,(PIN)
Sh.toltude and Unghttdc in dcgrec.0mimttaAccondsor decimal degrees. 22,Certification:
Orwell t4ettl,on:Word k sldtki td)
>, W ,Bra;n .Ewing;� . 11/30/2021
st�,n afCettiilicd Wd►,Comtaetor Date
6.Is(are)the wdI(s): Mrmanent or ts)Ternporary ftr sr�:nnx Alt fc .!hereby l rrio r;tru the nrrt(rt wwi(were)ctovinwed by deeasdaftre
eattr rsa NCAC OPC',ti1JX.m nr rJA NCAG t7.0.43t111 IYctr t'r�roatrresrian 4irrntkrrtalt wnd d�to
7.h this D repair to an eximing well: OY"- or O No ses,7>r of thin word Jum-bee a pent*W to Aw nWr owner,
Jf,nits h w ajWr.Jill me koems weft eow weton btfor,wwekm wW eaeptetln rfiie otamre Of Ole
c e,air rnMnr err c z .�,rhr era r cAcr fr r�r. 23.Site diWgm or additional rR eti dedtits:
You nmay itse the bacl,of this page to pm%ide additional-% a1 site details or weil
8.Number of wells constmted: 1 constmetion details. You may also attach additional pegs ifnecessaty.
For nwWrde Mjtvrtmn or reran-uwr j**welts ONLY nfrh tier con
,VbMtitaar fpsra. S1DBAfUTAL 111TST'I IC'F1'ONS'
9.Total welt depth below land surfaces 25 (ft) 24a. for AR Well r: Sobntit this loon Aidrin 30 dasl of completion of well
For matltok weth Use 011 VAT ff di*rrni(erQ sple•3@240'anJ7eE-1w) c(m5tntction to ttmetotton ng;
10.Static water leverl below top of easing ( .) M--&shin(if Water Resot ices,Ininrmation.Proe sing Unit,
J/ntrawr h t et tr uer efiaJog,ease"4' 1617 WI Sen ice Center,Raleigh,MC 276994617
11.Borehole diameter:2.25^ (in) 24b.£rtr Inirctton Wclkc ONLY: In addition to sending the femi to the address in
24a abov a also submit a-coley of this 1`orul within-10 days of connAction of well
12,Nell con5tnectlon Dxabod: DPT constriction to the foilmr•ing,
(i.e.=qw,meat~,atbia dime Venal.cle j
Dbicion of Water Rem PCtS.tTedetRtvnnd InJectttin Control Progsaatn,
FOR WATER SUPPLY 1VBLLS ONLY: 1636 Matt Semi cc Center,Raleigh.NC 276"4636
13a,VIdd(Upmn) McMad of teW. tic.For Water Sngwx&t&WOWMelts-
Also submit cite cop} of this fofni within 30 da)lof completion of
13b.Dicinfectfcn h'P Amnnnt: vveli conttnict on to the county hcafth depainnent of the county wbac
cansirtmcted.
farm GW-t No4b Camthm DqwU=aofEwimnmm and NatwW Resoumes_Dhis)on of Water Rewirom k0sed Attest 2013