GW1-2022-03299_Well Construction - GW1_20220314

WELL CONSTRUMION RECORD For ltacntal Use ONLY:
This form can M mcd for sink or multiple wells
1.Well Contractor Information:
14:VATER 20MLS
Stefan Smith FROM TO DFSCRIPrlt N
will co m:tctot Natne
3576A
NC Well ConlriciorCcnifnationNumber �1S.OUTER CASINGI(hetihad_ufls-0RLINER to lkable'
FROM TO MANIETHR. THIChNFSS MATERIAL
SAEDACCO Inc 0 fr. 5 ft. 2 in. 40 PVC
("oulvarryt 1111c 16AN14ERCASINGOR7'UBING eutsermaictaacdatxr�`;
FROM TO DLAINIF.TER I THICKNESS MAIT.RIAL
2.Well Construction Permit fi: ft. ft. hi.
Idtx rill apptlirable u-rll prnnits 0-r.Gfnrnh-5:41e,t;triarccr.711 EYDa1 rte.l ft. fL i>'•
3.Well Ilse(check)veil use): 1ZSC.RLCN .
Water Supply Well: FROM I TO I AIANIM—ft I SIOT677Y, I ToICKNINN I MATF.RIAI:
OiNgricultural OmulkipalrTttbllc 5 it. 15 ft. 2 in• 1 010 40 PVC
t�Geothemtal(HcatingFCooling Supply) Olkesidential\Crater Supvf, (single) ft• ft.
01ndustriiKomncrOil OResidential Water Supph•(shared) Tis'GROUT
FROM ?O. MATF.RIAt. T FMPI.r,CI:MENT 31MOD fi AMOUN'T
01ni ation 0 fl. 2 ft. Portland/beLTnembe
Non'Water Supply Well:
n: n.
®)Monitoring Mccovcty
injection Well; ft. fl'
DAquiferRcch,•rrge 06rouodivalcr Rcntcdiition '19.SANDimuVrE PACK it tlicitwe
FROM TO _I MATF.RtM, NMPI.ACCIAMNT IMMon
OAt uifcrStor.Igc and Recovery ❑Salinity Barricr 3 ft. 17 ft. Sand 2
❑Aginifcr Tcst OStomm-ater Dminigc
ft. ft..
OEsper mcntal Technology oSobcidcticc(,'otgrol
='20`-DRIIA ING'!'.OG7aftach gdrtitio>tal stxelsfncccasnan_ 1
❑rieothemial(Closed Loop) DTracet FROM TO MCRiPT101s kobr,hardnec,xatlnick tvpr.• ti A/Y 4l67
DGeothennal(I)Catio +Cooline Return) DOUter(explain under 62i Remarks) 0 ft. 17 ft. Sandy silt
ft. ft.
4.Date Wells)Completed: 1-6-2022 Well M#Mw31S
ft. ft.
Sa Well Ltrca►hm: ft. ft.
Camp North
Facilh,%-,0tvncr Monte Facilill•1D9(if appti:.iblc) ft. ft.
1824 Statesville Avenue Charlotte, NC 28206 Meckle,
Charlotte, NC, 28206 Plnsical Addicss,Citr.and Zip 21.aEptARKS:
1 foot bentonite seal from 2 to 3t. 9
tz,tiury Pattiel M116 i atiun No,(PIN)
Sb.l:atitude and longitude in degrees/minutcslseeonds or decimal degrees:
22.Certification:
(if well b0d,the 110-31V is suftickin)
35.248617 N 80.834746 ♦Y "-' 2/14/2022
Srgtul. ofCcYfidl4'cllContr3stor Dalc
6.Is(are)the well(s): 011'ennanent or oTemporury By signing this lone.1 herder orrlifv ibm Mr mvilfs)sms{mere.)r-onvinitrerl br ix-rordunre
tdth'l SA NC.AC 02C.01fk)or 1.54 AtCAC 02C:t1200))elf Cotrstrorrinn Srmafii/[lc rtnti Hurt n
7.Ls this a repair to an existing well: € Ves or CrjNo repy of(11if rer.0nl hn't lw rn pilpvfd,+o ro tlx to 11 int+ter,
If this ix a feimir,fill irmtkotilm well consinfalntr brformarionond exPlah due n,orure of rile
repmirmrderP21 rmnark%.%ez-jimr tie rut rbr brert nj'dtisform. 23.Site diagram or additional well..details-
You may use the back of this PI&to provide additional well site details or Weil
8.Number of wells constructed: construction details. You'iniv also attach additional palvs if nereMA1.
}Torowltlple iqjecrhmerrnwrtrraserxtrlpJriselbON/1'mils the some eonshucaon,�wucgn
azifnnit crttc jnmt. S11i11fIT AL.TNSTUCTIONC.
9.Total well do{tth below land surface. 15 (ft.) 24a. For All �Yellx:.'Subruil tliis':fann`wtithiu 3(t day of camp[clian of well
roe ittuitipte tails list afl(leFrbs if different(exatmple•3,+`M)'and 201W) construction to the follm,.ing;
10.Statie water level below top oftasing: (ft:) Division of Water Revources.Information Processing)Unit.
tl'-Ater 1.vel le above o ailgg uv"a• 1617 lllail Scn ice(:enter;Raleigh.NC 27699-1617
11.iioreholediiameter.6 (in.) 24b.For Inhrllon Wellc'ONL%Y: In addition to sending the torn to the address in
24a above. also submit a copy of this form within 30 days of Completion of well
12.Well construction method: Sonic Construction to the following:
(i.e.anger.rotmgy.:eable.direct push etc3
Division of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service�Ccnter.Raleigh,NC37699-1636
24c.For Water Supply&injection Wells:Wells:t3a Yield(gpm) Method of test: Also submit one copy of this fotiit within zD days of completion of
13b.DisinAYKiun type: Amount .rcll construction to the county hcahh depnrinrait of the coanh^-irhene
constr sited.
Fonn G11`•1 North Carolina Mpantimit of Ens irotuncitt and Nlamral Resources-Dit,-Dion of Water Resources Revised August 24113
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