GW1-2022-03305_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For Iiacnwl Use ONJ,l':
This fornivin tv oscd for singk or mohipk wtOls
1.Well Contractor Information:
!14.WATER ZONPS „
Stefan Smith FROM TO I DFS(111F n)N
W01 Cortriont Nanle A. A.
3576A
IS.OUTER CASING for'' foli easedw0s'ORLiNER s lkahk
NC�t+cllContraclorCcniftcotionNunleer FROM 10 MAAtF.TF11 Tf1lCK\FSS IATF,RIAL
SAEDACCO inc 0 ft. 5 ft. 2 in. 1 40 PVC
Colignill)-N5u1C 16..INN_ER ASIh1GOR7'l)SING jgcxtilhermalclowd FROM I To OLA\IETER THICKNESS M.11'FR)AL
2.Weil Construction Permit a: ft. A. ilr•
Lin all applir able u-rl/pr+mits(i.e.C.•otmh'..Suae.t'nrinmr,ljy rticri ev.)
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM 1 TO DIA%tr.Tr.R SIPTSITZ I Till(KINNS I MATP.RtAI.
5 ft. 15 ft. 2 in-. 010 40 PVC
UAgricultural iJMunicipiil/Public
17Creotherinal(Heating/Cooling Supply) OResidcntial Water Supph•(single) ft. ft.'IS.GROUT
©hldusirial/CoinnlcRual ORcsidential%Vatcr Supph'(shated) FROM To MATERIAL 1 EAtP1.1CFMLNT3IETH0D&AM01(NT
Olri ;tion 0 ft. 2 ft. Portland/benTn®)te
Non-Water Supply Well:
ft. A.
Mmanitorigg ORccovcly
injection Well: n. ft•
OAgnifcr Recharge OCiroundnalcr Rcnicdiation 19.SANDJGRAVELPACKfJ• ►lkAklkll -
YROM I MATFAIM. 0*11131ACIMIT-1 Nr r"OD
OAquifer Siongc and Recover• OSalinity Harricr 3 A* 17 ft. Sand 2
OAquifcr Test OStortwatcr Drtinagc
ft. ft.
❑Esperimcntal Technology OSuhsidcricc Comrol
20.DRHAJNCLOG:raitach additional shiels if i%e"Fri'
OGeothettruil(ClosedLoop) OTracet FROM TO DESCRIPTION(tvbr,hanfnoi,wil'nlekty 'riibe.tu.1
OGeothennal(Heatinatooline Return) OOther(c+( fain under k21 Remarks) 0 ft. 17 ft. Sandy silt
ft. ft.
4.Datc Wcll(s)Complctcd: 1-4-2022 Well iD#MW36S _
n. it. .
Sa.%Veil Location: ft. A.
Camp North n. to. MAR 1 4 2029
Fa61hy/0tvr cr Naar Facility 109(if appli ablc) fL ft.
1824 Statesville Avenue Charlotte, NC 28206 Meckle, ft• ft,
Charlotte, NC, 28206 Plnaied Addmss.Cite.and Zip 21:Nl OtARKS'
1 foot bentonite seal from 2 to 3'
(`nwtlyU Patrel Molirs=oi(tn'No.(PiN)
ib.Latitude and Longitude in degrecs/minutes/seconds ar decimal degrecc: 22.Certification:
(if%sen k1d,one latno;is gnnickial 7►
35.248916 N 80.830981 W _ �_ 2/14/2022
Si; -ofCcYfi4i-c)IContraclor�' f Mf x ^x Date
6.LS(are)the well(s): xiPerinanent or oTemporary M aret+ing this(rive,L herehr ornifr tiro the wellls)t vs f r+rtr)ronvimcled in aeearrhmc-e
with 15,1 1vCAC 03C,010)Or)M AICAC 1P.C.0200 Well CwistrtvetRni Sra,rlards amlllxlt a
7.Ls this a mpair to an existing well: OYcs for MNo rnf»ajrhis rrcnrtl harMn+(Nr>i'irhd rn the slvllnuvi�r,
If this is a wimir,foil Ixu Lnmol wellraltstnfalon hrfoalmrlond11d atplain the 1101ere of(he
rrlarir ureter A21 rr+nnrkc sr.^tiw+or cv+rhr brML bf rhix jnrm, 23.Site diagram or additional w'cll details:
You may use lite back of this►age to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pigs if oxessan'.
Fur,nt,NpJe PgIeerkm a ar6'i-11-arrr I(.ppir welh ONLY o4ih'(he some comiraahm.yet,can
.caJ>)tir one form. SI BMITJ'AIrJ,j�,C-TCIGTI jVy
9.Total well depth below land surface: 15 (ft.) 24a, For All Wells: Submit Ibis fort within 30 days of completion of well
F'or mahiplr+rolls list all drllrhs 1f diRwent('eamapte•3@2170`wi(l 20 ilk)') construction to lice following;
10.Static water level below top of casing: (n•) Division of Water Rcl�oumei,Information Processing Unit,
lfowet level is Movie casing,we"=" 1617 Mail Sen•ice Center,RalcW NC:27699-1617
11.Boirhole diameter.6 (in,) 24b.Fnr 6lleefion Welly ONLY: in addition to sending the form to the addrtss in
24a above. also submit a copy of this fonn within 30 days of completion of well
12.Well construction method: Sonic C0115(mctioil to IIle following:
(i.e.anger,rotan',cable.direct push cte.)
Division of Water Resources,Underground Injection Control Progrun,
FOR WATER SV'PPLV WELLS ONLY• 1636 Mail Service Center,Raleigh,NC 27699.1636
t
I3a Yield(gpm) Method of test: 14c.For Water Supply sic injection Wells:
Also submit one copy of this form within 30 daysofcomplelionof
13h.DisinfiyKion,flpe: __--__ __ Amount: __ . lvcll conctmclion to the coomty health department of the crnmtywhetc
constructed. '
Fomi GW-t North Cmolim Deproocni of EntirDtuncia aid Nalaral Resources-Division of I%l erResourm Rcs•ised At(gust'_N)13
I