GW1-2022-01355_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD \� For tftrual Vsc ONLY:
1hn form con be used for single ov mW[ipk stills
1.Well Citntrworluftlrmation:
'A4�It ZA;
Brian Swing FROM IDPSfretPtrtJh
W01 Conttacior Nana
4240-B 1t. fL
NC-'Wd)ComiactorCenikmflroNunber iS.f)rJTPdtt.AS ( or iN 8. t} '1dt�i l tteafik ':
aRort MATERIAL
SAEDACCO Inc 0 fL 9 (L 2° ift. SCE-40 PVC
CaaaparryNatrre f6«1 7tTIMIIf{sI" ie dtioledfi
FROM 170 1 DWIRTER I THK1KN.Ss MAIERIAL
2.Well Canstrvetion Pcmdt#. th ft a►
1r"atpll:Pp tientair weft fram("(Le.Comm Star,uruionrf,hoc den eml
3.Well Use(check well use): 17.St;17 `1 t
Water Snppfi Rac1t: FRO'" TO DiAlrrl YK0 Sr t z I Ttn-(%NM. I Ar TitRiAa
OAgricultural t MunicipalPi'ubGc 9 R. 24 (f. 2" Ia 010 SCH-40 PVC
cGeotherml(RealingCool ng Supply) cResidential Water Supply, kngle) ft. IL ie
DindusttiallConinlacial gRcsidential Water Supply(shared) Btt;RtltfT '
trRixm To htAT[iRlRt. 1 ffi1PtAC*X-M-T 7a VMOD AMOUNT.
Dhrt flan 0 R. 5 (L PORTLAND POURED
Non-Water SUpplFWe11;
�hlonitutin gRvcov ti. ft.
Inde,relfln*Veil: ft. tt.
0Aqu*rRcchargc DGttttrndwaterRemedinvon 1 SAAt1r 1, A !9f
❑Agnifer-;SMge and Kern,,cry Malinfly Barriers aR sf t< Frrtn a.rr�TMwr ri
7 ft. 24 (t FILTER
SAND # 2
0AquiferTw 0S1ommvcr Vmimg:
Di V,crimenlal Tbcbnotq v gSnbsidenec Comml
=20.1>Rti Ai+rG1X.4Sr rafmtc[i ttldiilmit0shcels
aGeothernral(Closed Loop) DTmcet FROM TO PESCR►PtrON tat.b1rdn v nr+xe a*r.o
DGeotheoamal(Heafi off Return) 00dier otdamwider421 Remarks 0 (L 5 ft. FILL SILTY SAND
5 ft. 15 ft. MOIST SILTY SAND
4.t)ateWel1(s)Conmplettd: 12-10-21 WdlID#MW-l0R 15
(L 24 h: WET SILTY SAND
54.Well Lneet Orr,
Charlotte Law Enforcement Center A (L. JAN 2
r%Q1 tsit u w Nam Faci ily M#(if WpIkebic)
ff. tf,
1006 Elizabeth Avenue, Charlotte, NC, 28204
Pht3iwJ ddmss 01t 7.andZiP 2777
Mecklenburg BENTONITE SEAL 5 TO 7'
Cary Paced htini(tearlou No,(PIN)
Sb.I atitude:and longitude in dcgr+eeslmirmleslieconds or decimal degrees: 22.Certification:
Of welt foold,Mr Wlova 38 sidt"Muurt
W Brig n Ew.i ng.. 12/16/2021
Sirs ,saran of Catilim Well Comactot
6.Is(arc)the»eli(s): OPermanent or oTe mporary ; ,lA
Rfi S k Ims.f .1 hetrby rxmJy rhrd thr nrtlpsl wrls dttrrrl rxfttrruwrrd in dcrerrtnnie
nvrlt 1,54 NCAC OTC AIM or rfA NCAC W,OM Wett COostmMoot StlraR wds and l&t e
7.Is this a repair to an exi tiing well: MVcs or ONo ropy ofrhLr rera W ho bi"i.jnnn4 rat ra;hv n !owwr.
tforalsormair,,frtlaxarkroomt:,0cgtrss wvtmtt bm3atlnn and exf.daln the mrtneof:fir
repair under#11 mwtks Amfi wa or on the bark of iNsform 23.Site diagram or additional well details:
ay You m use the back of this page'to OM%itte tnWiiitarlal u�ll she details or%tiell
8.Numb"of wells constructed: 1 construction details, You moy also iittaeh additional pages if nemsarg.
F'or ana(tatplr irt*i&urot reran store:AqV*vtxtlr ONLY n1rh Me same c onstrnrtlart.pau ran sttBltlri'LA� �.S#tf svhM t MW fnrra. t
CTIONS
9.Total well depth below land surface 24 fft,) 24a. Per A WtI v: Submit this farm vithin 30 days of completion of nett
For anul1wr a ells list tr114epAs ff dtlfewnr(rrtrr&-3@Im'attad:2@7f1WY) constriction to the foltowing;
10.Static Water letirl below top Of easier. {fL) Division of Water Rcq+ urees.toformation Processing Unit.
1f ttxrtrr keel is above ratiaiv,tare„+ 1617 Mail Service C n cr.Raleigh,KC'276"4617
i
11.Dowimle diameter:8.25° tia) 24b.For Ink Won 3W13 ONLY: In addition to sending the form to the address in
24aabove. also sarbmit a copy of;this foram within 30 days of completion of well
f 2.kil;construction mabod: BORED eousttnctien to the lollowitmg:
(i.e.anger usury,cable diced pntL ems.)
Dl islon of Water'R,esvurcv*'Urrdergronnd tinjcetlon Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Stnice Center.Raleigh.NC 2 6"-1636
134.Yield(gpm) Method of tcs1: Esc_For Water SoUll&tnjoctina Wells:
Also submit one cap} of this form within 30 dat}s of completion of
vmll construction to the county health departm znt of the cm"teh
131a.Disinfection type: Amount ete cansrmcted.
Farm Caxlr-t North Carotins Uepattumt of Emiroww n and Natural Resources-0hislon of lt'e t Reowces RsrL%,d Ateul 2013