GW1-2021-02815_Well Construction - GW1_20211013

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WELL CONSTRUCTION.RECORD for l lUwONLY:
'nis form con be ased.for.sb*or ndlltpk aclis
A.Well Camtnwor information: f
ia.N112'It1t;1i01atF�
Stefan Smith 9R M A Ifrf Y
UVI Contractor Nn of y tt fi,
3576A �C, 13 ZOZI R. h.
NCWdCoaftworceniticationNnTltbcr U �jllit 3,6t #?R 5fbiti ore rtti�a frk _ OR 1N1at Neitile>
f�Ce.a' t� FROM, To I1fAME8li1t 7fItCKSE34 MA7ER1Ai.
SASDACCO Inc IPa�iCf'3' sec 0 (L 17 ft. l" ia. SCH-40 PVC
sec.!
ComtxttryName. 4 3t N�OR�JITBIN i' rya`
PROM TO DIAmEUR I TInCAN M MAWRIAL
2.11ttAlCstn#tntxionpw�m(t#: 50000079 ill
ft. (4
t o at1 apptiraNr-wrU pennitt(rm,Calmly.Same,varianrr,I*Xfh r rtr: (L
3.Well Use(theck well t>6c}: A i_
Water Supply Well: FROM TO I 1 1Ah11
1
TAT 17} IT TW 1 MATlIH1A1.
OAP�ultuTal i Municipatlfl�nbliC 17 (t. 22 ft 1° in .010 SCE-40 PVC
Meottretmal(Heat{ngtooting Supply) DResidential WaterStipplp(single) rt. 1�
aIndustti.I/Cammeiriat DResidential Water Supply(shared) a alto
FROM TO t±L%TMtAL Ebtr1.ACF24M- Mc91101)A AMOUM'
Dlrrigndon it. fL
Hair-Water Supply Well:
mmonitori t7Raa� �'
Tolaot Well: fL ft:.
DAquiferAccharge DGnnindwatcrReowdistion 'S."
13At{aifcr$ Cthud = Malini •!Barrier a i tAiratnt. RrfatA roar pn
tWtlb � � 15 tt. 22 ft. SAND #2
DA11uifcr Test Ostomm•Rter Dminmc
Mxprrimcntal Tcchno{og l3subsidemc Control
`10:�. It�lal+it3t,, : ' Etit(loii'tY heett'�flicccstan �.. ,
[Geoftnual(Closed I,00p) CITracer FROM To RE$t RI pY Dilly axNh ff WwMk n rErattf.
DGeolitenual(Heati ll Remm) ❑Odw(otplain under#21 Rern&&) 0 A. 14 ft. silt
14 AL. 30 R. Sandy silt
4.Dafe WclI(t)Colnpteted: 9/1/21 WdIID#B-10
n. IL
Sa.WcU ineathrn: (L (L
Shell Oil Products, US fL (L
FaC0kAl)%VWxt Basra FooMy 1DN(ifopplicabie)
fl. ft.
101 W. ifoodlawn Rd., Charlotte, NC, 28217 ft. R.
t'lgsicelldd�ess C^ity'.enezip 2t: to l4,. _ 77, 1> :- ;,<
Mecklenburg 16903203 Temp well for groundwater grab sample."
Caodw tarns!1dealiwtiaoNo,(NN)
5h.l dibidcand Longitude in dcgrecvlmimtteslsecondsor decimral degrees, ,Certification:
(it well fkK me-latttong b$WTft dfd)
35.178722 N 80.884078 W �W.UC
�m,d ..�.b� �, 9/28/2021
SiAmt of Sodracrot Datc
6.Is(are)We stell(s): UPertnaneat or ZTempotgry fi s)a s ahu fo m."t A:ashy rertrJy Au do w rll(s)wot Iwesr)cipnrtnwed M teirerAmtr
wj*15A"NCAC 02C.0100 or 15A NCAC 02C,OIQ911 Well Camas -*on Srandardf and thm o
7.Is this a repair to an odidul;well: Mies or i@NI) �mi�rdr�mr r„�h� P.m tad r�arar,�rrt{m�rr.
1fri4ls rx at ai�rttr.fire a>aar trwn.rf w tri enrrstrueviaaa 1#omwttrwr mad#-.Wt*b1 the smrHre of air 23.S{tt d
reywir an der#21 rnaarb srrrrm or an Me bwk n/ewes form. {A !and OY fddllFDliil rf dl.def81{S:
You]njq,*SeL the ba&of(his page'to ptmide additional shell site details of well
8.Ntrrobcr otwcits ronstrticted: 1 construction details. You may also anach addrtionat pages if twessafy.
Forma hlple lqj tf m&fawn-waxer ATPJr UWM ONLY Kilda Hm owner const miffiafr>.yor ran
x*b=ft mW farm. SU13MMAL M19MMONS
9.Total well depth below land surface: 22 (ft.) 24a. Far All Wellu Subnit iMs.form,.tiithin 30 dnys cf ottrttptetion of anal!
far anu iVt w9s lice ell tkp ft ytd�ffirrrm(exeiv pfr-302W awl 2@1 constnu ion to the,following:
10.Static Water Iml below top of cssiro 19 (pi.) Division of Water Resourtee,Information Processing Unit,
If natrt lever bmove fasrfa5,am"+" 1617 titan Se niter C 6kr.It i*!h,NC 276".1617
11.UotehllFc diameter 2.25 24b. rLjlt an"Wetls ONLY: `In addition to sending the fount to fire address in
24aabowe.also summit a copy of this fomt within 30 days of completion of i%*Jl
1Z.�`C11 aMsi netlon moo nod:DPT c nistruct{on to did Itf)1DWiiip,:
(Le.angen rotor}•,csbld d'M pusb.etc:)
DE<•G91on of Water Remo f+cea.UtTdergronnd ieJtcttoe Control Program,
FOR WATER SbIT Y WELLS ONLY: M36 Mart Smite CatHet;Raleigh,NC'276"4636
13a.YFCId(gym) Method of test: 14c.For Witter Salrlllr&tr ec"ot Weds:
Also submit one copy of this form within 30 daps of catuMetion of
13h.Disintixtion b1m Amtmnt: WCH conshiicfion to the county heddih dgmdmcr4 of the cot",u*m
constmcti
Foam GW-t Nonh t amiins 1)4vA m of Ean4m m no said Morons]Rmwmcs-Dn*lon of Water R Rc%,isca AtVA 2013