GW1-2022-04880_Well Construction - GW1_20220525

'ikmt CONsutuC`TiON RECORD. For iracr.ml Use ONLY.
ThErrorin can be its:d for sinNtc or mdipk'tec4ls
i Weli Contrletor information:
li.WA7ER LONFS
Stefan Smith FROM TO 1 OF�('mr1jor"
t1'cit Corir�tpor Narnu-
fit. fit..
f6 fit. I
3576A
NC�Vdl Cantinctor Ccniflcalion hmrber `1.5.OUTER CASING{for raulll ca%ed%0h)OR LiNER tit a a Ikable)
FRov[ - TO - nN}It:TFR 7TtIC6�TiS5- -\[ATF.RIAI.
SAEDACCO Inc 0 (t!: 109 (t 6 in. 40 PVC
C n tni't ana, iti.INNER CASING OR TL181NG 1 eritkeneA cluscd-luP )"
FROM TO DLOIFTER= .TUICiiNESS I MATERIAL
2.1 Well Constivctinn Permit!, 0 ft. 122 A. 2 Iai 40 PVC
lin II(ugr7icahfr sceilnenuits fix.c6ull v Raty 1"Irk ince,711`e:tif tCie.)
3:W01 Use(chctl h�Cll,usc):• 17.SCREEN
Witter Supply<l'dl:.: FROM .I.To . Dt+Art'TTR sttlrst�r TuiC1t511s t INIATEw,ar:
CtAc_.r,uku[aI Clhftmicip:lUF'u61ir 122 ft: 127 fh 2 IM 010 140 1 PVC
fl. fG" in.
c16cothermal(HcatingiCooling Supply)- OResidential.WatcrSupply(single) I
©llldttstriatlConmt nlal DRcsidentialWaterSuppty'(:sbarCd) FR0 �� TO %MTERL41. ENPL%CEMENVuL'tt10D&ASIOUNY
i7trri alion. 0 ft.' 118 it. Portland./13enTomte
Non►tir Itcr Supply Welk j
�14toaltiorinl;: 1311amzn•
Injccfion Well: n. fL ,
OAquifcrRcchargc OCsninndnalcr Rcutcdiation 19.SANDIC RAVEL PACK(if u r dkabarl
Tn aL\TF,RI:+I;.. :. .. b:\1PLA(:F71a:VT Vl:THOn.
L7,aquifcr.Stgmgc aiziRecovery C15ahnii�BTmec 120 Q 127 (I. Sand 2
DAtliiferTcsl= ❑Stoml++ItcrDraina�c iL fit;
❑E>lrrimcntal Tttihnatogs OSubsidcncc Control. -
20.DRILLING LOG tonach additional shears tf ecce%sar+)
DGeothennal(Closed Loop) OTGlcet' _FROST TO DFSCRTMONImhr.lmrdnc. wil'-wk6pe.pAintzrwl
❑Caotttennal(Ileatine'Cooliae Return) Miller{tee I rni uiidtr�21-Reulalis) h.; It.
75 it., 130 ft. Rock
4.Date Well(s)Contplejcd: 1-10-2022 ;Wel11DMMF131s it. it H, � A ��•�.t � '
52.%'ell Location: tt ft. ,}--(�y�'
ty A 2
FacilityMurcrNnmc FacilitplDk-f+fspl+li�b)c1, fl.' fit.
z,sr•c. �s-.,,r.
1824 Statesville:Avenue Charlotte, NC 28206, .Charlotte, fill rl;
NC, 28206 FlnsicatAddrss Citi^.andZip ''' '`'t'' i ' "�
L REl11ARK.5'
Cenitst�^ 111me)hk:nl fic7tivil No:(PL%)'
51t.t aptudc and I iinfiitadc fin ileFlresltninutcslaccands nrdreimal dpgrcvs: „ Ccrtireadnn:
ot%' V11 awld;Olk LrLlulu is,autiici_sd},, - 2 -
35.47358 N: 80.832683 W 1/10/2022
Slga rQo CHied:Well Contc, Date
6.hi-(al )-the.1YCII(J}:'�XPennanent, or- Metnporary' fi,•,suing thin jaim.;I lrirclir twdfG drat t;Se well(sl wu{rcrc)cu"AIATC161 itr(wCerdan,e
frilJf 75A NG1G02Cr.(/lft7 0�'1S,t\'CAC ak�204 well Co umii tim Sf,lrklnr 15 and dsal d
7.LvtttiSarcpaiCtoalfGIS11R�'hcll - dYea or KNoI... Ctlii;pfffilrrrranilulclrarnr>rirl.drntl nl�llr,uirrr.
lfJh(S 1,17 replir fill tau kawern+rll scrr,ntttrc.n lrrl,rr u ri Jt m d ctplitlrt rht ak true njdir
rellriuur,.lcr•A'l.rcmarkesrrlimaarrtafh hrdk:ojrrdsjanii. 23 Site diagram or additional++clldel ails-
Yon lnay,use,tbr bacl:of this Nge,to pto+ide additiotuil+vi:ll sirz,delails.or well
8.Ni m icr.of wells constructed: cailstiuction details'. You may also attach additioriat pages if tnticssan•.
�Ur rr ultll letojnvr l?n ew rra r fii;er ntppls a rJts OAVU.u.di rli ,fame epirstrurtion,}c v Coo
Aa6m."ton,jorra. ,5..UBM1TTAL iN41 1C'1IONS
- ' 127 2a.L Fiir�All Yells Sabnut [ids form-within 30 days of completion of well
�.Total well depQt lielon land sunlit 00
For,rntla�7rleellflisr all dep;k_fiidr sonstnrctionto.thed,follalting;
l0.Static uahr:level below top of easing: (fill) Ui+•tsfun Of�Yater Resources,Infgnnatiun Ptnccssing Unit,_
ff nzrJcr level is sLwc:cgsisa ux l6171%W-Service Center,Hatei26,NC 2 76994617
t1:Iinrehn[cdiameter:6 (in) 24b.Fnr 6llectinn Willy ONLY: fr addilion.to sending Ow fornt-to tlk addr�ill
24aabove..al_zo subinil a copy.-of this form +citbin 3Q doys:of colnplctian of well
MAY ell co6tructionmethod.BSA/Core/Air construction to the!toll ill,
cablc'dircctpusketc..)
Division of Water Resourres,Underground fnjcctiou Control Progruit,
FOR WATER SUPPLY WELLS ONLY:.' 1636 MA Scn•ice Center,Raleigh,NC'27699-1636
l3 i Yidi1(gpm) llctllod of test 21c Foe Water 5upplt a&injcctinn'Wells .
Also submit one copy of ilia fonn i0l iu 30 daysofrontpletion of
+clUcotutnution to thc'coimtyhealth department of dic coiinlacn•hlere
131t Disinfccnua t`pe ; Amount, constroacd.
Fonu GIV-I Noilh tfmfini Depannient of Eavironnicia and Natur t.ftcwurces-Division of wnief ResowcF, Raised lug�t 2r113