GW1-2022-03376_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For I mcnial Use ON LV
This form can be owd for sink or nuollipk-wells
1.Well Contractor Information:
4.WATE It ZON US
Stefan Smith FROM TO WSCRIP',"ON
Well Conran Narne ff.
3576A
NC AkIcH Contricior Ccn ific3l ion Number IS.OUTER CAUNG(for' ullktiw�ed.*4107 LINER(if 4 to kah1c)
FROM TO 1`114MVITFIt- THICKNVII-S MAIrERIAL
SAEDACCO Inc 0 ft. 6 ft. 2 in. 40 PVC
("onvaill K.1111c -16;INNER CASING'OR TOBING intlecrmal' wd4
FROM --L-T-O D1,10IFTER TI"CKVFSS MAITRIAL
2.Well Construction Permit N: ft.
list all up-phrable we-it permits(i.e.Couny.S)a.1r.Voriamee.Irix6at eje)
It. If- F
3.Well Vic(check well usc):
Water Supply Well: FROM I TO I DIAMMM' I SLOT WX I THICKNIN:5 I MATERIAL
OAgricullural IDMuniciNiliThiblic 6 ft. 16 fl. 2 010 40 PVC
043co(hermal(Ticitingtooling Supply) 011csidenfial Water Supply(single) ft.
(31ndustrial/Conuncrcial 011csidertial Water Stipph,(shared)
FROCROtIT M I TO INIATFRIAL I F--IPLAF'FMtNT.,4trTnot)&AllFt"INT
ElIrrigation 0 ft. 3 ft. Portland/behTumite
Non-Water Supply Well- I
A. ft.
®Monitoring 011ccovcry
Injection Well: (I.
0Aquifer,Recharge 06roundunicr Rcinckition 19.SANDK;P,%VEL IIACK fffalgilkably)
FROM TO MATFRIA1.
0 Aquifer Storage and Recovery DSaliniry Hirricr 4 ft. 16 ft. Sand 2
ClAquitcr Test O.Slormwatcr Driinagc
IDEV. crinacrital Tcchnology OSiibsidcncc Control
',241:DRHAJNGtOG feltacb joldilionit0reis it mvestary)
OGeothenual(Closed Loop) oTrdcet FRO'M TO DWRIPTION ftobr, Aiv.w.j
[]Geothermal(Heati ogXooli tie Return) []Other 4explain under#21 Reuia*s) 0 ft. 16 ft. Sandy' silt
4.Date,Well(s)Completed: 1-11-2022 Wdl,ID#NW32S ff. ft.
51L Well LAIcation: It. ft.
Camp North
Facilhy/Owncr Nanic Facility 109(if applimb1c) A. ff.
1824 Statesville Avenue Charlotte, KC 28206 Meckle, p, p• IVIAK 1 4 ZD77-
Charlotte, NC, 28206 Pl%lsical Addrrss.City-and Zip
1 foot bentonite seal from 3 to 41.
County Parcel Wsairication,No,(P I No
5b.Latitude and Longitude in dcgms/mInutcs/wcnnd,or decimal degrees:
(ifuell field,One latloq is gldrlei�!nl) 22.Certification.
35.248658 N 80.834503 W 2/14/2022
Date
6.Is(ar%)the well(s): kPennanent or OTcmporary If signing this form,I hereb-i e,rfify that roar aellf.o sms(m rir)e—Littucted in&,cordanre-
wiffi 15A XCAC 02C.01(k)or 154 AICAC aX.0209 We// standards(IjIlf VAI o
7.Is this a repair to an existing well: 0Vcs or ENo rrvy(y,(Ilis rerwyl ba,%tern pm0drd to she uV-11 MOW,
If I h ts is a I eim I P,fi 11 two:W r;i rn well ronsin(mion I j tfo ana r/ft)i and exp tob 10 1 e oh-i ru re of doe
relwir torder 021 r"narAwn-efion or cm the hark of di6jorm. 23.Site dialzrant(or additional well details:
You mat,use tore bacl,of this 1xige to pfoNide additional well site details of well
R.Number of wells constructed: construction details. You utay also'auach additional palv's if necessan'.
For'"I'Mrit 1'qJfeI)kWI oa argi-warer sjppf%is-t-111 0XV,10111 dor some comstruedon, Can
SUBMIXIAL LNSTUCTIONS
=Omh one form.
9.Total well depth below land surface. 16 (ft.) 24a. For All Well: Subinit this tbrin within 30 days of completion of well
For ma biple wells Ho 01(MIAT jidift;-rew(exarnpte-3@209-awl 2e my) construction to the following:
10.Static water level below top of caging- (ft.). Dhishin of Water Res6urm.4,Information Proccising Unit.
If-walee,level is 471-ore cwtog,are"4 1617 Mail Setwice i..entcr,RAlcigh,NC 27699-1617
11.Borehole diameter 6 24b.For ItIlecilitil MIL,ONLV: fit addition to sending the font to the address in
14a above. also submit a copy of this form within ail days of completion of well
2
12.Well construction method: Sonic construction to the following;
(i.e.anger.n3un.,cable,direct vask etc-) Dhislon of Water Rcsourms,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Senice Center.Raleigh,SC 27699-1636
13a Vield(gpm) Method of test: 2-Ic-For Water Supply&Injection WelLs
.
Also submit one cop), of this fbion within 10 di),sofcompletion of
well construction to the county Health c1cp-mment of the c4minly where
13b.Di*inf4xtion type:___ Amount:___._ constructed.
ForinGW-1 Xconh Catalina MWitnient of Environincat and Natural Resources-Division of WlicrAmaLroes Re%-iscd Aqgus;('-Ni 13