GW1-2022-03298_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For litcnial Usc ONLY:
This form can be used for singtc or multiple scc[Is'
L Well Contractor Informations
ai►►'ATER ZONLS-
Stefan Smith FROM TO DESCRIPTION
1t211ContrtctorNarrte
3576A i
NC Well Conincior Cenificaiion Number 15.OUTER CASING(for'atuhi•caseil rills)'OR LINER tiUati kable
FROM TO DIAMETER THICKNESS MATT,RtAL
SAEDACCO Inc 0 ft. 79 ft, 2 1 an. 40 PVC
t,trllltnaill'[�.911M '76,'iNNER CASINGOR TUBING -eolh¢rm_ale6seddatp�': _
FROM, TO 0 MFTF.R TIFICKNESS MATLR1AL
2.Well Construction Permit N: A.
lJo all applirable a-N pe—its(i.e.C•owity sta n'.lUria"re•14xtiaz err.)
fl. ft. in.
3.Well Use(chat:well usc): Y7:SC.RCEN-
Water Supply Well: FROM 1 TO DIAMM11 I SI,(ITg?Y- I Tlll(`K\r:SS I NIATF,RIAL
bAgriculturat OlViunicipcillPtlblic 79 ft. 89 tt. 2 in; 010 40 PVC
045eothemlal McatinglCooling Supply) ORcsidential Nater Supply(single) u. ft.
Oindustnal/Conlnlcrcial 011csidential►triter Supply(slclred► 0.GROFROM UT 'TO MATTRIAL i F.AtPLACFNEIT3ET110D.6A111011;,T
❑Irri ation 0 f6 74 f1. Portland/be Tme dfe
Non-Water Supply Well:
ft. fl.
bMonitcirinR ORccovcry
Injection Well: ft. fL
0Agmifcr"Rcch,•irge Drimundunicr Renicdiation 19.SANDIGRAVEL PACK(if ilieabk
FROM TO MATERIAL FMPI\fY;M i:-�T MI:'1'H D
OAquifcrStorigcatdRc1ovIl}' ❑$alinin Ramer 77 ft. 90 ft. Sand 2
OAgnifcrTcst OStormw-itcrDrtinage ft ft
OEN. crimcntal Tcchno[ogl• OSobsidencc Coroml V, DRn LING LOG(attach additional sheds if tic o4m
❑Geothetinal(Closed Loop) ❑Tracer .FROM TO DWRIPTION(color.hnnrncis,witnickis n.4mokl
❑Geothenual(1•leatinpiCooline Retutn) OOtlwr(ell lain unifier#21 Remarks) 0 ft. 37 ft. Sandy silt
37 ft. 90 ft. PWR
4.Date Wells)Completcd: 1-10-2022 ,Wdl(D#MW32T
n, a.
Na.Well Location: ft. ft.
Camp North
Fac7ii}:-0rcncr Nantc Facilhy IDF{if appli ablc) p. ff. Q 2�
1824 Statesville Avenue Charlotte, NC 28206 Meckle,
Charlotte, NC, 28206 Plasical Addles.City.and Zip
21.REMARI(.S'
3 foot bentonite seal from 74 to 7711,.,;,•,:
Coital% Mite]ld.ul fiGtliuttNo,(Pt.N)
fill.Latitude and laingitude in degrecdminutesiseconds or decimal degrees: 22.Certification:
(if melt field,ow t:urlotig fig sldlicicn()
35.248658 N 80.834503 „ Si cull ofC ck46:dt►'dllractor Daic
2/14/2022
G.Lc(arc)cite well(s): 3ilPennanent or ❑TemlKrnrry JA.signing thisfirim,l herehr rertif.•that the nrlJis!arts(writ•)morn acted in tweordnnre
with 1.54 NCAC03C.01(y)ar!SA A'CAC 02C.0201)Well Cmnsrrrark-n Staylnrrls amlllnlr,r
7.Is this a repair tit an existing well: OVes or ®No copy,nf this rrcnnf has her»pmild-d to lhr swil tn+•ncr,
If this is a pgmir,fill twit knrdlvn av ll rmtrinirtion fq/on+xtrlra and esplahn doe nnrare of(lie
rrlbrir artrlrr A21 rrmarkr sit^lion ar rut the hrs•1L of"thixloon, 23.Site diagram or additional will details: ,
You mn.use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details: You'mav also attach additional pages if itecessan'.
For.muldf4e i rjtVt)on or ntNr-warer sapltlr•wells 0M Y»•frh(he sane eonsrruclion,yen con
lulu»it one form. S TBh11TTAL"INS'603O S
9.Total well depth below land surface: 89 (f6) "24a. For All Wells: Subnat this form within 30 days of completion of'lsell
Fr,r nriihipfr�crtlrJ(srnl!depths ljdiff'rrrnr(cxmnpfr Hs:09'final 2 ltl)) consttnction to the following:
10.Static water level below top of casing: (ft.l Divishm of Water Resources,Information Processing Unit.
lfasrlrt level&whore cniiug.iom"_" 160 Nail Service Center,RatcW NC 27699-1617
.11.Borehole diameter-6 (in.) 24b.Ur lniection Welts ONLY: In addition to sending lite font to lite address in
24a above. also sUbmil a copy of this farm within a) days of comple ion of well
12.NVcll construction method: Sonic constnrction to ate following:
(i.e.atilt r.lilac•,cahle.direct push ctc.)
Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLV WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1636
13a Yield(fp►m) Method of test 24c.For Water Supple'&lnjecti nr;Wells:
Also submit one. copy of this f6riii within 10 days of complel ion of
13b.Diainftttion type: ___ Amount: well constnivion to the counly !`le:ilth dcilminirnt of the colm w ty here
constnlcicd.
Finn GeV-I North Catalina Wpiti cin of Etnirotuttcat andN ainral Resources-Division of Kate`iResouMes Revised August 2()13
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