GW1-2021-00550_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD For lrftm l Usc ONLY:
This-form can be amd f0 singk a mullibk nvtls
1.Well Coutntrtor Informailon:
fx�}TA4Rdt ZC1
Brian Ewing Fn M ot-eitltivllOY
WC11 Co" t w North R. ft.
4240-B
NC Well CaotmclorCerliG;CMalion NnntScr .4 40UTIM C.AI-MUNf3 r' iflt tiot+l OR,f flcabta
FROM I TO lltAI.%W ..R TMCJCVFM 1 MAMIAL
SAEDACyCO Inc y0y (L 13 I; 1�. lid. SCE-40 PVC
p
FROM am
TO DWI [tiR I TttlCt+'N SS MAiF,RtAL
2.%Velt onstruction Permit#: (L tt.
Liu all eppiiru6b well pennio fie..County.Su",Vnrinfere,ftftceen or.)
ft, tt. ift.
3.Wdt Use(check well use)- yl
Water SO Wdt: FROM
13 R, TO WAMICTRR ,ilAlTBrr.E '"11 MArrRtta,
13municipallmlir _
�� ' 23 (i 1° to 010 SCH-40 PVC
f iAg(icttittlral
Moothermal(Heati ogling Supply) DResitlential Water Supply(sirjk) tL it.
iu
R I
01ndusnW/Conimetcial Mosidential Water Supply(Slated) F: ClRQ1�
FRAM TO MATERtA.T. H:IiFLA. `. T Mti[ItQA fi Amoixf
01nigation ft. tL
molt-Wate3'Sapplf WOR:
i monitorin Olterctti ti h.
rn]e'ctlolt Welft n. (L
0At)4*rRe0arge 00ntundrtwerRcmcdiation
PR � m A't't:R4Lt.. t+I:A .,rr.:rzt/r:rrl n
❑Aquifer Storage And R,ccovviy QSalinity S atriet' 11 M 23 ft. FILTER' SAND #2
0Aqui er Test ❑5tommVer bmivmSc
l hnoto C1Sobsidexlcc Catttml fi. tL
Mverimcnlat
10.R'R?f 'Ui iitla@b % tlmlr<f<Medsltsor
OGrathetmot(Closed Loop) OTracet FROM TO Dtesexn ON #c."c6
OGeothentml(Heetit of Retttrtt) L]Otlter t n under 421 Rematl:s % tt.
4..Date Weil(s)Completed., 11/15/21 Wdd ID#TMW-1 1
SanWe111.tteatilln: fi �
Charlotte-Mecklenburg Hospital Authority !t. tt 0
FacilftyA) wrNome Fneflih•Rik(itappikibli)
-
1000 Blythe Blvd., Charlotte, NC, 28203 fT ry
ftys9atlAddmsr,City.nod Zip 3a.:RHI►i
Mecklenburg Bentonite seal from 9-11''
Castitny Almd tdtittifkr f0a No.(1004)
5h.Latitude and Longitude in deglredminutalsecainds or decimal degrew. 22.Certification:
Orwell Otte WoM1%stlf -ktd)
>� W .Brig n JEW ng, 11/30/2021 y�
stgar m of�n�od Wcfl OD,ftwtot
6.Is(are)the.well(9): EPelmanent or oTemporary $F signing ti&jonm I herek,ttirn*that rhr wefAfvi tubs f etend t tnsmtered in cXti aim m
with ISA AFCAC f12C.(ilW or 134 ATAC.02C,02W Well Comtroalan Starden(s and dw.a
7.h,this a repair to an existing well: t Ves or MNo r ofthir r"ord has two,l mvkkil m Oie.tril owner.
syAts it a repair..jilt 4w knot:rt well con action hrfomwrkin and r piaht she aronare of the
rrpairnnderd?l remarks srrtitw ortm she hmk of this farm. 23.Site dtWam.or additional Neti detalts:
You may use ft back of this page to proAde additional well site details or tail
8.Numbe r of wells constructed: 1 construction details. You(tlac also attach additional pages if occessaty.
For nwhiple injivrW or orm-tturer xW tar#r ONLY midi the aarmt consRuretlon.vew can
su6vn%rant,(oetr,. �$jl'j�7'I`A-1..(N�'f';IC"17
9.Total well depth below land surface 23 (((.) 24a. For A[1 %11s: Submit this form within 30 dayl of caompletion of aril
Frrmaddple ttxlls fisrall deprrbr f1dt,(fcrrnr feamrph-302MY and 3@1tk7'f ca:r gruckn to the following;
10.Static USUr level below top of easingt (ft.) Division of Water Resources,Itxfonnstion Pmmxasing Unit,
If womrWei isobrme tviing.use"+" 1617 Mail Seniec Cc 1m,Raleigh,ltlC 276"-1617
11.Borehole diameter:2.2 s° (1n•) 24b.Rrtr(nfecttan Wells OItiLY: In addition to sending the foot to the addles in
24a about also submit a copy of this form within V days of completion of Wl
12.N81e11 eorstructirm!method: DPT construction to the followhig:
(Le.mt r.ratan)•,ambit dimes push eft.)
Division of Water Resources.Underground infection Control Program.
FOR WATER SUPPLY WiRLLS ONI 1636 Mail St nice ice Center.Raltdph.NC 27649-1636
13a.V414(Mm24e.For Water SoeWv&Ipjection.Wells:
) cHtad Also submit one cop of this fomt trithin 30 days ofcomptetionof
13b.Disinff lion h°ilr Amount- well construction to the caimnr health dcpartlm n of the county where
e
constructed.
FormG%V-t NorihC,amlinsDeTwumnufEmimnmetaand!datum!Rcwwws-Ditii0onofWatcrRewwm teOwd AqW 2013