GW1-2022-03377_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD Forlracnuil Use ONl.l':
This fonncon is used for single or mnllipk scclls'
1.Well Contractor information:
:U=WATERZONES. ;
Stefan Smith FROM TO nINCRIPTION
Well COr intFtnr Naote
3576A
r 7S.OUTERCASING firmuNi�casedec11s-0RIAM if:a-�-lkable
NC 11 cl1 Comractor Ccnifnation Nuntbct
FROM t0 DIAMi,TF,R� Tft1CKNFSS I MATf,RtAh
SAEDACCO Inc 0 ft. 14 ft, 2 in. 1 40 PVC
Congran Name 16.INNER CASING OR TUBING'(eoiberinat 41owdaoiso).
FROM TO DIA 1IFTER TIIICKN[SS MATERIAL
2.Well Construction Permit#: A. ft. in.
Litt tell alrytli.-ab/r ua•l1 rrrranitr(i-r.C0101ty;.S&r.e,-1'nrirnrcr,lnfE 664 eta) n. ft.
3.Well Vic(chock well use): 17:SCREEN
Water Supply Well: FROM I TO DIAPNFTER Ng7$t7f. TIII(T(NF\5 MATERIAL
UAgriculturll I Municipctl/Ihtbltc 14 ft. 24 ft. 2 in, 010 40 PVC
OGeothctmal(1leming/Cooling Supply) OResidential►Eater Supply(single) h. ft. in.
OlndustrialfContmcrcial ORcsidential Water Supph'(sneered) ]9:.GROUT -
FROM TO MATFRIAL EMPIACF.MENT MMIOD A AMOUNT
❑ltri ation 0 ft. 9 ft. Portland/bea'EneMILte
Non-Water Supply Well:
SLMonhoring Oltccovcty
injection Well:
OAquifcr'Rccharge OC"und%:Ttcr Rcrucdiation 19.SANDM.PULVI!LI'ACK(it lkaMe'
�!!l
TA MAT►RIAL NMPt A(Y;V`NT Mr"tFll)n
❑AquiferSioragc and Rlti/nrn' ❑Salinity Barrier 27 I'L sand 2
❑Aquifer Tcst OStomm;rtcr Drrinagc tb
Oryrcrimcntil Tcchnolog• OSubsidcrlcc Control
20=DRi.IJ 'G'LOG`tattach additiiriel�heels)f+ieccisan
OGeothenual(Closed Loop) OTracet FROM TO DF;SCRIPTIONftolir.hArdncc<M-1lrmckn' 'e.f+e.lre.t
OGeothennal(Neatin tooline Return) []Other lex lain under 021 Remarks) 0 ft. 27 tL sandy silt
ft. ft.
4.Date Welf(s)Completed: 1-13-2022 WeII ID#MW375
n. n.
5a.Well Locathm: ft. 11.
Camp North fl, ft.
FaaiMy/OtcncrN1mtc Facility IM(if amtinblc) fl. ft.
1824 Statesville Avenue Charlotte, NC 28206 Meckle, ft. ft. 4 2Q
Charlotte, NC, 28206 Pit%sical Addmsc City.and Zip 21 Rl I►fARKS
31 foot bentonite seal from 9 to 121. .
t oonh Patecl 16.j liric:iuunNU.(PiN) -
Sh.L:ltitudc and Longitude in dcgmcrJminutcalsecrmdc nr decimal degrees: 22.Certification:
(if fell kid,ow kttlottg is 5tdlickno
35.248617 N 80.834746 W _< .,, _ �. _ 2/14/2022
Sigrut, ofCe:rficd Wcll Contr>?,tor Date
6.is(are)the N'cll(y: -xiPerinartent or oTemporarl' I herebi e•rrn s dirt thr nril(s)sws nrie i•a.nsvuc-ted is tx'eordemte
Hr ire;nin}thi9(eenn,, j� ( !
u•ilh!M NCrte 02C.011)or 15d kolC 02C.0200 Well Cortstr ripen Sram0ds and dust a
7.Is this a repair to an existing well: OYes or N No raps nj rlih reronl has Ir rn pryrrid.A to ahr lull owner.
If this is a rep+tir,fill Co.*kno"VI well eownifedon htforawtrion m41 explain rhr wrnre of the
relrir loaner 021 mnarkv se.^tian or on the bark nidd.v farm. 23.Site diagram or additional well details:
You may use tine back of this pogo to provide additional%veil site details or well
S.Number of wells constructed: colistluction details: You may also',attach additional plrges if tea essary.
Far mnldpfe i tieerion M niNw.-firer lnppfo hells 01V7.Y ri•itlr fix•some constraselion.vnlr C&O
.%utnnir one form. SUBMITTAL,INST 1 .T10NS
9.Total well depth below land surface: 24 (ft.) 24a. For all Wells:. Subnol this form within 30 days of completion of well
Fair rrwhiple tcells list 01 depths ij dlfl}rent(esmatpte.,@200'(awl 20 M'i construction to the following:
10.Static water level below top of easing: (ft.) Division of Water Resaur'ce!t,Information Processing Unit.
If isme•t level is alone casing,tse"+" 1617(hail Service(:enter,Raleigh.NC 27699-1617
11.Borehole diameter.6 (in.) 24b.For iniection Wells ONLY:' In addition to sending the fount to the address in
24a above. also submit a copy of this foam within 30 days of completion of well
12.Well coot mntction method: Sonic construction to the following:
(i.c.augm unary.cable.direct posh etc.)
Division of Water Rcsounes Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 276994636
t3a Yield(g1►m) Method of test 24c.For Water Supply&Injection Wells:
Also submit or* copy of this forin Aviihin .10 daysof completion of
13b.Disinfettion type: _ . __ Amount: %veil construction to the courtly heallh dcparimcni of the county where
constructed.
Fonn GAr-1 Notttt Caroliar D.rnnnlcntof Fncitounocttt and Natural Rcs<iutces-Division of w'aierResouoes Rcrised Angus%2013