GW1-2022-04218_Well Construction - GW1_20220419

-'' WELL CONSTRUCTION RECORD
\ For[ruerml Use ONLY:
Tits farm son be uscd fnr>;mgk or nudf.ipk nr8s
1.Will Contractor Ittforutadon:
Brian Ewing .� RryM Tt) r► GutwtlryN
HrcliCniatmUoritarne a Z R. R.
4240-B APR 18 2022
NC Well Contractor Certification Number 15':OUTER C ING 4tWf1Ttl4i5ed-firctlx ORIfiKERi' licaMe'. ,.' 4'T s 'd
FROM To DtA,+1ETEl . TtriMNM A ATL'R1,1L
SAEDACCO Inc Intorpriation Propoemirto Unk fL fL tit.
Cda%t,mytJank I&JINXIER. G;0Rs77lB1NG
FROM TO DUNETER. fIIiCAi4E55 ArATEAIAL
2,Well Constmetion Permit# 0 R. 43 ft 1" SCH-40 PVC
List ollaspillraole well pemrio(ke.County.Stull,Variaare.7tlTe 04 r1r•.) 0 •ft. 17 ft, 1 iM SCH-40 PVC
3.Well Use(chccli well use): 21:SCft1 EN:� ����• � ,x�,. .4 ���-
—
Water Supply Well: iRryttt TO vrvv it st;arstrw 7mcw ems_ I NATOOAL
0Agriaulturai Dmunicipal/Fttblic 43 R 48 R,' 1" ia. UlU SCH-40 PVC
ClGeoftfutal(Ilealin o 1 ) CDResidentiaiWaterSu 17 R. 27 n. 1" in .010 SCH-40 PVC
1� lio g Sti�y Supply(single)
01ndustrial/Comrttercial ©Residential Water supph(ststr�d) 1rr'CRO[lT r,. : y. ;:.4.s, .A � z= ,r.:-'a
FROM TO. NTATEPUL EMPLACEMENT AfVMGD R AMOUNT
❑hl'it3 itrn 0 R. 13 tt PORTLAND TREMI
Non--Water Supply Well: IL ft.
f�)4lonitorin C7lteco� '
ift ectlon Well: R ft.
C7A1)tr fcrRccttarge C]CrrourWv crRcrncdiation 99$ANb/t:ftAf/EL1'At 'f " ll btk
.Pttry;ti MAt!k'AAf. Mt4 _.
OA uitcr Storage and Roeoxe ry C]Salinity Qamci e�T tin o
41 R, 48 G, FILTER SAND # 2
DActutrterTest 13S4onmvatcrOnvinaga 15 R. 27 ft. FILTER SAND # 2
0EVCrimcn(al7'echnolea 0Sirb5idcnecControl 3r�:11R71111 1OG:fsilach.adififio"" nalaticct3�lfheccsssi^w '`� : -
❑Geotttemral(Closed Loop) l7Tfnoer YRryM TO DESCRIMOti**br.lierdnen affmcR o rprt+,eft.1
❑Geotitetmg(Reathg2911ge Remnt) ❑Other ain undera121 Rematl s) 0 fL 15 fL FILL i SILT SAND CLAY
15 fL 35 ft. MOIST, TO WET SILT/ CLAY
4.Date Welt(s)Coalpleted: 3-18-22 WellW#MW-0l-D/MW-0l-S 35 it 48 fL WEATHERED CLAY PWR/BEDROCK
Sa Well Lneataln: fL (L
Former Countryside Cleaners fL ri.,
Fuc11#y DK,oer Name Facility IDN e3f applicable) ft,
3007 Zeus St., Charlotte, NC, 28212 ft. fro
Plgseculilddte5s City.and Zip 2i'It'lF1ASKS.
Mecklenburg NESTED 1" WELL; BENTONITE 27-411 13-15'
Cxmttly PaMT1Ide1tiftc.10011:No,(PIN)
3b.Tahiti and L.t ngitude in dcgreWmim ites/5econdsordecimal degrees: 22.Certifi Cation:
(tt well read,one 4w7ons 1A su flrleal)
1, W Brian ng.. 3/17/2022
SignVam ofCertifrcd WeR Contrirtor Doe
6.is(are)the well(s): oPerntaneut or ❑Temporary By signing Aft foam,1 hereby certify d.jar thr uWl(sj asas(Croon)e�marnrrred in oreorduner
with f5A NCAC 02C,Of00 or l SA MCA,02C,020f1 Krell Constrriedaa S(aadardi and that a
7.Is thj6 a repair to to v i."Nell: OV&S or ENo copy ofrhtr rmord has bma nrm,1rrc4 W)ftr aarli my ter.
If tits ISO bg maatkw and rfatrilat the naraire of Me
neeWir undert21 rnna rks swakm or an thr brxk nJ this form. 23.Site diagram or additional w'eil detaFl3:
You may use Ills back of this page 0,prtiNide additional well site details or well
&.Dumber of wells constructed: 2 arnlstluetion details. You may also attach additional pages if necessary.
For muitdp a ikWikui tv rim-mate gwA IPWIS ONLY t4rh flip Same rnashwctlour,y"roan
=Nit ranc form. SUBMITTAL.tNSTti('1TONS
9.Total well depth below land surface: 48/27 pR;) 24a. For Alt Will Stlbnii this form aithin 30 dates of completion of well
For nmMple NrNS lisr aff ift--olio ftdWvrruv to orTre @@ VP`oral 2@ IM) construction to the foltgwing-1
10.Static water level below top of casing: {ft1 Division of Water Resourtm Information Processing Unit,
1f u utr a kwo dS above aaaing,use"+„ 1617 Mai SciTice Center,Rnleight NC 276991617
11.Borehole diametcn 10.625" ( ) 24b.Egr 11112 ion Wide ONLY .In addition to sending the form to the address in
24a abom also submit a copy of tans forth within 30 days of completion of well
12.Well consirnetion metbod: BORED conslnretion to the fnllouing:
(i.e.mpr.rotary,cable,direct posh etc.)
Dh'ision of Water Resou rcesr Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27694-1636
13a Yield(gpm) Method of test: 24c.For Water Supply&injection Weds:
Also submit one copy of this fouu within 30 days of completion of
1311.Disinkvtion tips AtltOrtitt: uvil constntctton to the county health department of the cotmh,where
constnutcd. C
Form GAr-i North Camltna Dcpartracmi of Eaviroamtent and Nanual Rewtoces-DiussMn of Rrafer ltesoum Rcu-iscd AtrgL&2013