GW1-2022-04518_Well Construction - GW1_20220509

WELL CONSTRUCTION RECORD For Internal Use ONLY:
a— This form can be used for single or multiple wells
1.Well Contractor Information: ?
-44 WATV
John Eisenzaan TO D'(-'RlP'n0N
%Veil Contractor Nwe A. A.
fi. ft.
4439A 7d
NC Well Contractor Certification Minter i5.'0MR CASING(farntuttl4atioslivi0s)- RLINER(hie ntoolkablel,
FROM I TO PLAMETFR I Tl111C1KNF—',S I MATERIAL
SAEDACCO Inc
0 It. 30 ft. 2" In, SCH-40 PVC
I
Conipally Name 16ANNER CASING,OR 71l81NG eotlk 2lt1Dwd4
FROM TO DLkMFTER I THICKNESS -I MATERIAL
2.Well(:,on--tructiion)Pcrmit#: tL to.
I.ist all j7pplirallir w-rll prnnits(Le.Cosmy.Suar.Variance.lrear&n em.)
3.Well Use(checli well use): 17 SCREEN
Water Supply Well: FROM TO I 111ANI1.TER SIOTS17T THICKNINS I MATERIAL
OAgricultutal ONlunicipal/hiblic 30 h. 40 ft. 211 .010 SCH-40 PVC
OGeothennal(ticating'Cooling Supph') 011esidential Water Stipph-(single) ft. ft.
01ndustrial(Conuncorcial 011csidential Water Supply(slured) I kGROUT
FROM TO MATFRtAL R's1P1ACTMENTNlrl1fOD&AI#1011,NT
[31frigalion 0 ft. 23 111. Portland Pour
Non-Water Supply Well: ft. ft.
Oilmon' itoringg 0RccovcTy
Injection Well:
0Aqui(cr'llecharg 0433roundn-acr Rctuccliation SANDMI14LAVEL PACK
FROM TO AfnTFR1A1,
0Atluifcr.Siorigcand Recovery Milinity Harrier 28 A. 40 A. SAND #2
0Aqui(crTcst O.Stornrwatcr Dminig ft. ft.
0EV. cFinacnlal Technology 0,Sitbsidcncc Control .
10.DRILU 134 NG10altacb additid
013eethemud(Closed Loop) 07fracet FROM TO 11PSCRiPTION uobr.blird"Vil,uNmeklype.0%in An.4*3
0433tothenual(Reativgtooline Relton) 00dwr(tNplain under#21 Remarks) 0 ft. 40 ft. clay�
ft.
4.Date Wcil(%)Completed-. 4-19-22 Well ID#MIN-2
It. MAY 0 9
Wilson Carpet f1. ft.
Fact hy�'0%vn,cr Name Facility iDN(irappitabic)
20850 Catawba Ave., Cornelius, NC, 28031
Ph%sical Address.City.and Zip
21.RENIAR&
Mecklenburg bentonite seal from 23-28ft
Imccl W21firicalion No'WIN)
Latitude and Longitude in olcgirrcsiminutciAccondf,or decimal 4icgrecN: 22.Certification:
fifuell field,one W-long k qunicizid)
N W 4/20/2022
Sign0RUM Of Date
6.Is(are)the well(s): or OTemporary W.1fim"Fr-
z-olutmeted in
with 15A AICAC 0.1C. --,uC'02M filell stal0wils and 11KFI ty
7.Is this a repair ft)an existing well: oves Or ENo copy of this reennt Ims been pnil-rde'l io 11w ityll mcner,
If1his is a 10poir,fill finer knolm Ivell consinwilan III/OrypWrion and exp0hi the nalare'Af rile
relwir"Wirr P21 molarb sevrlion rah cm the bm"t ofthislarm. 23.Site diagram or additional well details:
Y611 may use the back of this page to ptovide additional well site details or well
8.Number of wells constructed: consunctionde details:
. You mayalsoatiachadditional PlIVsifliecessin.
For,wildple injeeilon of atvj-worerrwpl�l•s it-ells&VIA'w[rh the some con3frurtion,y0a con
m(wiliti'lleform. SUBMITTAL tKSJUCTIONS
9.Total welt depth below land surface: 40 —((1.) 24a. For All Wells: Subtitil this fonn within 30 days of completion of well
For irtumple evens Una(/flepthOttlifferou(cxwPp(e-?@2W"11Sd 20 l&Y) contraction to the following:
10.Static water level below top of easing: (ft.) Division Of Water R eou orces,Inflormation Processing Unit,
lfwmer level Is above rasiog.we 1617 Mail Servicel,Center.Raleigh.NC 27699-1617
6. IniMijitto VCILONI'%�:
11.Borehole diameter. On.) 24b.For lot addition to sending the fooron to live address in
24a above. also submit a copy of this fonn within 30 days of completion ipletioll of well
12,Well constoruction method: Air constructioll to the fbllowioe:
(i.e.anger.rotary,cable,direct push,etc.) Division of Water Resourcts,Underground Injection Control P,rograln..
FOR WATER SbPPLV i'VELtS ONLV: 1636 Mail Servicetenter.Ralelgh,-XC 276"4636
13A.Yield(gpm) Method of tot. 24c.For Water Supply&Injection Wells
.Also submit one copy of this form'within.10 daysol"completion of
13b.Disinfection type- Amount: wcIt construction to the county!health c1cpnrinicut of the coxtinty.wherc
constructed.
ForrnGW-I North Carolina DeWnian of Environincia and Natural Resourecs-Division of Waicy ResiaLrem Rcviscd August 2011