GW1-2022-03323_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For Imenial Use ONIN:
This form can tL nwd Cat sinPk or multiple%clls
1.Well Contractor Information:
i141.WATER ZONES
Stefan Smith FROMfl
TO orscouPrtON
Well Contractor N11nne ft.
3576A
NC Well Cornmoor Cenification Number 15 OUTER CASING far inahi cased':rcfit"OR LINER it a ikable
FROM To ruAMETEa THICKNE&s MATERIAL
SAEDACCO Inc 0 ft. 30 ft. 1 2 In. 1 40 PVC
4ongrl1ll NamC M.iN.NER'CASING ORsTUB1NG eolbermat.cimcd!tgi)i
FROM _ 70 1 UNMETER I THICKNESS MATCRIAL
2.Well Construction Pcr'mit#: ft. rt. ut
list fill applirable well prnnitr(ix.(7niaeh•:Stine.l nriarrre,14tr8al ele.)
rt. fl. in.
3.Well lisc(cheek well use): 17.SCRLEN
Water Supply Well: FROM TO DIAMETER SUOTSIZF Till (NNS I MATPRIAL
OAgricoltural 0municipal/Pubtic 30 ft. 40 to. 2 in. 010 40 PVC
DGcotherural 41-1cating/Cooling Supply) OResidential Water Supply(single) tL ft. in,
©industriaUConmtcrcial ORcsidcntial Water Sloppy(shared) FAROGROUT-.TO. MATFRtnI. E\fP1.tCF NFhT N}"RIOD fi A 1fOUNT
Dlrri ation 0 ft. 25 h. Portland/be'Toemkte
Non-Water Supply Well:
A. h.
I�MonitorinG ❑Itccmrry-
Injection Well: n, ft.
DAquifct Recharge DCronadn-aler Reniediation 19.SANDMI AVEL PACK WaliliCabte
FROM 'r0 M%TFRIM, P.NIPI\fY'11ENT M 1-1'f10n
❑Aquifer Storage and Recovery ❑Salinity Harrier 28 A. 42 fl. sand 2
❑Agnifcr Tcst DStormnater Drainage ft. f.
❑E\:perimcntal Technology O.Subsidencc Comrol
2tn:OR11:L1NG l OG attach addilional sheets iftoevvya'rs
❑Gcwdiemtal(Closed Loop) DTmcet FROM TO nFSCHIPTION(tulrr,ha dn@si,IoWnwkupe.grtin tive.tv.l
OGeotlictmal(Hcatin4lCooline Return) ❑Outer(ex lain under 921 Remarks) 0 ft. 29 ft. Sandy silt
29 ft. 41 ft. PWR
4.Date Well(q)Completed: 1-19-2022 Well iDpMW39T 41 to. 42 fL Rock
Sa.Well tAlcation: h. tt.
Camp North ft. U.
Faci1ily7Ouncr,tame Facilh%lop(if appliulblc) fl, ft.
1824 Statesville Avenue Charlotte, NC 28206 Meckle, ft. ft.
Charlotte, NC, 28206 Pln'sical iXddress.City.and Zip 2t RCNARKS'
3 foot bentonite seal from 25 to 28'
(:aenrty 11=0 td uldovifiun No,WIN)
5b.lattitude anti Longitude in degores/minute\/scerindc or decimal degrees: 22.Certification:
(if well field,m.Ktlluq i&sullicwtn)
35.246540 N 80.833403 W 2/14/2022
Sigruu of Ccvficd�Gdl Conu tctor Daic
6.is(are)the ivell(O: ZPennanent or OTemporary ftly signing this form,I herehr eeriifv dmd Me.nrllfs)uwx fmw v)evaruueted ht imxordanre
with 15A NCAC 02C,01W or 15A A161C 1t2C 0200 Well C+nrarru,a tut.fdaviaals raid flan a
7.Is this a repair to an ex6tinR\fell: OYcs (or IgoNo t Vy of this rernn'l bv,,%1wrn pnmided io)hr roll owner.
if th(s is a wpoir,fill twit(• olvet well cotunm Ilan lnfomurritnr(Intl a xt)(nbt rile torture of doe
repair under 021 mnarkv.vre iem tor rut Me bru-4-tiflhivloan. 23.Site diagram or additional woell details:
You may use file back of this page to pfo\ide additional well site details or well
8.Number of wells constructed: constroeliondetails. You may also attach additional pages if mexessary.
For mnldfle iajeedon ar nra-u-mer strpp>v wells ONI,1'w•irlt Me some eomtrursion,you can
.eubinit one form SUBMITTAL.INS UCTIONS
9.Total well depth below land surface: 40 (ft.) 24a. for All Wells: Subndt this fonn within 30 days of completion of well
ror tnalliple wells fist all depths lfdif ervis(evamp(e-.?Q2M'and 20/W) construction t4 tote following;
10.Static water level below top of casing: (n,) Division of Water Resource+,Information Processing Unit,
Ifwater level is above rasing,tom"+" 1617 Mail Sere icet'cntcr,RalcW NC 2 769 9-1 6 1 7
11.Borehole diameter.6 (in.) 23b.For Jul! lion Wells ONLY: to addition to sending dic form to tale address in
24a above. also submit a copy of this fornf w•itlfin ?0 days of completion of well
I2.1Ye11 construction method: Sonic construction to the followilre:
(i.e.augm roar}-.cable,direct pub.ctc.l
Division of Water Resources,Underground injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Nail Service Center.Raleigh.NC 276"4636
13a.Yidd(grpm) Method of test: 24c.For Water.supply&Injection Wells:
also submit one copy of this form within 3A0 days of completion of
13b.Disinfection type: __ _ Amount: _ well construction to the county heahh delxmmcnt of the coimty.whcre
constructed,
Form GW-1 Norlb Carolina Mpann)ent of Eno irotunetn and Natural Resources-Di%iiioa of Water Resource Revised august?ti 13