GW1-2022-04196_Well Construction - GW1_20220419

WELL CONSTRUCTION RECORD For trftnwl Use ONLY:
This form can lx used fur single or mWtipk w cIls
1.Well Contractor Irdormatiorr
14.WATEIt ZONES
Brian Ewing FROM I* t►MCRlYtlnI
N`cl[CniNcrcfrsTNarat ,cEN R tl
4240-B t�
NCrWcJICordmaorCcrlificabbaNTimbcr APR 2022 $.:0[ITEBGif'ilhlGdfar iuTTiisiss�ilti► T1 OItLINER.[#fi 'k)cabk ""
FROM Tit 1)M1%TKRR TtAGta-N S" 70.1"TAL
SAEDACCO Inc 0 ft, 6 tL 2^ io. SCH-40 PVC
CAStNG'tIR'- B ehr 1NG " E4iafit ira�1
Comp,my Name lcaw --Q MANNER t
Irk D\VQJ�� FROM To oWVJER THICKWESg I MAI UtL
2,Well ConstrucOon Pertnit#: fL ft. d►
Lw all apphrffble werlltrmrj#s li r.GnrcrnN,S?urC,Vnrinrtco,Ti CDrirl err,.j
ft. fta irk
3,Well use(chedr well usc):
Wafer Supply Well.* T� PtA\TKTRR STAlTSI7f, TfirCrCNMS MATFSRIAT;
OAgricultuml 0municipallmlic 6 ft, 21 ii. 2^ IA• 000 SCH-40 PVC
❑Geothermal(Heating£Cooling Stpply) OResidential Water Supply(single)
®Industrial/Col►unercial OResidential Water Supply(shared) FROM TO MATEMAL EMPLACIniMTVWMOD&AMO1Wr
❑Irii Lion 0 ft, 3 fL PORTLAND POURED
Non-Water SuADly Wiff:
®A4onrtorin p�ov �» fL
Injection Well: rr. rL
❑AquifcrRccharge ❑C,roundvmtcrRcmediatiar►
❑Atlnifcr Storage and R0G4t Ty ❑Salinity Burner rR rf _ _ fAEF•,kLrL t2MP1 A Y1ti'�V kllau yf
4 R, 21 ft, FILTER BAND # 2
❑AgtrifcrTcst ❑Stomm-atcrbminagc
❑ =Krimcnial`I whnotoa OSubsidcricc Cordml
10.,BRIM NG WOG`a'rfaeh�idvfilione131iciysttnecc�sa"
❑Geothermal(Closed Loop) []Tracer FROM TO DESCRirnu
❑Geothermal eatir Cools Retunm) ❑Gtlter(explain under#21 Remade) 0 fL 5 fL FILL SILTY SAND
5 fL 10 ft SILTY] SAND
4.Date Welt(s)Completed: 3-17-22 WCIIIDaMW-06
10 ft, 21 rL SILTY SAND CLAY MOIST TO WET PWR
ia;Well Location: fL rL
Former Countryside Cleaners (L fl.
Facifty/Chvner Name Facnhy im,of appucdwe)
ft, ft;
3007 Zeus St. Charlotte, NC 28212 Mecklenburg Coun, ft, fL
Charlotte, NC, 28212 Pl pica!-Addmre s.Ci .andZi -
4 4 P 2t i2rl►1Akticr'� r ,�
Mecklenburg BENTONITE SEAL 3 TO 4'
Ccrrrr Parvel rpcnNt�-IdDallo,(PIN)
Sb.Latitude and Longitude in degrl ostminutcsAcconds or decinuil dcgows. 22.Certification:
(if w ell roictd,wic I;147uns is srdf e3eor)
11 er
W r! n_Ew—i �!�,5, 3/29/2022
sigrouimofCeniffcdWdICentmetor , Dsfe
6.is(are)the well(s): zFennaneut or aTemporar}'
lly signing chat farm,1 here$y rcrrify rljar the mrll(si vwr thrrCl ean3lnrtled in af'cdrdanre
u•Irfr f 5A NCAC 02C.0100 or ISA NCAC 02C.020f/ii'l/Coararrrfcrioa Swndards and that a
7.la this a rtpair to nu exi5tid vYCl1: ❑Yee (or KINu copy of nisi record has been pfmrltkd r,'Ow-vfrll mvmrr.
If Afs it o rtpalr.fill cayr kw-,Kw uvll c&wnrMcmi irr,lanwskm mod erpinhr.6t a eunmre of the
repmir wrder 621 mmoffa x fP n or rna die hfxt of fllfs form. 23.Site&Vrarn or additional well detallA:
You may use die back of this page to pruvride-additional well site details or welt
8.Number of wells constructed: 1 consancdon details. You may also'atlach additional pages if necessafy.
For,mo Mole At rkwi cx coral-lo arer mrpwjv twills ONLY bIrA rho same ronstrfrctlaor,WW cvrf RGQ�ifTTAL 1NS'fUC.t7ONS
n4adf one firm. — .
2.Total well depth below land surface: 21 (ft.) 24a. For Alt Wells: Gthndt Kris form vdlhin 30 dzgj of completion of well
For li7 ) con5inration to'Ihc fottoviing;
10.Static water level below top of tasiug: (n,) Division of Water Resources,Information Prom mug Unit,
if rcwicr levci is droty rdsiryt use°+ 1617 Mail Service Center,Raleigh,KC 27604617
tt,Borchelt dismctcr e.25^ ( ) 24b.For fnicetion @Relic ONLY:` in addition to sending the form to the address in
24aabove. also submit a copy of this form within 30 days of completion of well
12.Rfc11 toostruction.nlvthod: BORED construction to the fdllolving:
(i.e.eager.raary,cable,direst gash ctc:) Division of Water Resoumes,Underground Injectioft Control Program,
FOR RATER SUPPLY WELLS ONLY: 1636 NA Service Genler,Raleigh,Nk C 276"-1636
i
13a,l'idd(gpm) Method of test: 24c.For Water Supply air 1pjcaion Wells:
Also submit one copy of ties folhn %ithin 30 days of completion of
v
131).Diiinfititian type: Amount: mll comstnrct an to the county hp alth d rtmew of the ccRrnty wh=
' eoR�raactcd.
i
Fanu MI-t Noah Carolina DepaAamlof£miramrcna and Vanuat Resowces—DivisionofOValer Rcnowm Revised Ar.tgtmt 2013