GW1-2022-04882_Well Construction - GW1_20220525

WELL CONSTRUCTION RECORD For fre,r 11 Use ONLY-
This fornlcaritlz used foi,sintleor rnultipl:i%ells
1.Well Contractor Infriemation:
iJ.WATER'LONE-S
Stefan Smith FRO\1 1-'10 1.pF_SCRIFTION'
N'cllCorinctorN.-nw
3576A ft. I ft.
NC%Vcll ComractorCet ift6ti6n Nntiber 15.OUTER CASING(for Intihkased hens)OR LINER lit a tkabkl
FROM I TO mAmvTrit TRIMNESS- - t1ATERTAL
SAEDACCO Inc 0 ft. 61 ft. 6 in. 40 PVC
cdovauty`Naltn: iti.INNER CASING OR T MING t vaulkrma]cktscd-Io/r v)
FROM TO I FIRMETi?R TUICKNEMI slATERIAL
2,well Construction Permit K: 0 ft. 74 ft; 2 - 40 PVC
Lisr itll cjwlirnhle Iscf7 p.irriU fi c:Cnurni;Stmr,l nrintrce,T13EYdCO rst:j tl. It.
3.Well Use(cherlc\roll,psc): 17.SCREEN
WaterSUpld\'Well: FROM - 1-TO _MAMETTR SLOTNIM -till" E��- t \tATERCat.
DAgricultnral i N-lunicipiMu.blic 74 It. 79 «: 2 in. 010' 40 PVC
©Cnotkimal(FicatinglCooling Supply) DRcsidcniial'WaterSupply(sinpte) ft. !I. in. '
❑ludustriallComnicreial 011csidential\Vita Supply(.shared) FR.GROUT
FROM TO' \I,\TERC\I. I E\IPL\CE3ILVT\fE'illOn A.S\IOL�T
❑Irri plalion 0 it. 70 iL Portlafnd/Be*TmEdLt+
Non-Milner Supjily Well: t
f1. fi..
B&IIonitoring i]Rccox-cry
Injecfjon Well: it. iL ,
❑Aquifer Rccha,c OGroi ndn:afcr RcuiLdimion 19.SANDI(.RAYEL i•A(:R fif II r double)
FROM TO ►1ATERIAI. EMPIA(TAKATMt:T110D
❑Aquifer Storage and Rcca\•cry ❑Salinily Harric( 72 «. 79 41. Sand 2
❑AquifcrTcst 0510mmatcrDminagc_
❑F\TscrimenlalTcchnoloag 11Subsidcricc.Control
20.DRILLING LOG(arlacb additional nbeets if nreessarv)
❑Crotlwntal(Clused Loup) ❑Tracer FROM TO FIE5CRr/T70�!rube,Fxrinc.,x,u'ntet Ir rc. man :rc.cttl
❑Goodtunnal(Heatini!+Cooline Mum) ❑Otlkr(explain under 921 Reutaiks) I ft. It.
(t. It..
4.Date Well(y)Completed: 1-10-2022 Well ib#MW43B
«. fL
ft. iL
Facilitl,O�crlcr Nnfnc Facility i6k(if aypkablO ft. ft.
1824 Statesville.Avenue Charlotte, NC 28206, Charlotte, ft. D.
NC, 28206 Ph%"s%al A(Prss.City..and Zip. 31 REMARKS
(,,�,tC
Com I 1 ravel 1&-Iil 1'e—alion.No,MN)
ib.l,utjttldc slid I.ongitittic in dcgireslminutcsfscconds ac decimal'dcj;t res: 22.Certification:
(tf_i%elt r"d,orc I uaott i+stt111ca;td)
35.47358 A 80.832683 eta' 1/10/2022 -
Signal arzlofC�11cd Well'Ccfluncto7'-� Date
6.Is(are)the.wcll(s): MPcnnanent or ❑Temltorary By.1i rdng this kwr•t herrin•reriift•than tl!r,n r!!(sy ur (isrq l cvrxfYn ctcd i t erecprdirnrr
Ire"b 1511 NCAC 0JC.Rl n?or 15.1 NCriiC 02C.0 00 Well Con3micdou Snukfan!s and slkts rr
7.C\this a repair to an existing"ell: f7YCS or Mi c Vy of rh!r man!has brrn jv rvided in the urll rnrner.
l j tbis'fc n ayxdr,fll rn,rCtednp weii ronsmiction 7tt joralrui-�n and exploht de narnre,f rile
rrlwirru;Jrr B11 rrrstarAs sr.•iian nr on the bark gfthii form- 23.Site diagram or additional well details:
You niay-use-tli back of this page.to provide additional well site details or well
S.Number of iiells constructed: cons«uctimi details. You nfa\:also:attach addrhottal Pabtis If to t ess ary'.
Fur m1drill4 mjex-fio t arriail-rea;i,r iflpj y welh ONLY with the arrmeeostsriuerion.,yna+ecin
svtbndtnnejovn• SUBMITTAL INSTUCTIONS
9.Total n'cll depth beloti la.ml.suriace.. 79 (ft.) 24a For All �Vdls:: Su.bnfif tl►is form withiti.30 days of completion of l\cll
For nuthip!e,teella list ail urepibl ifdU;i•rehi iexraapf<-:z�?0:7 oik}2e I(?n'k con5finetion lU the folloi\ing:
10.Staticwater level below top of rasing: (ft.) Lii isiup of�ti'ater Rcsuurccs 1pforrlation.Prccenin'Unit,
/J,ecurr letel k above rtis(ng:use"t•• 1617 Riait Sm ice Ccntcr.Raleigh.NC 27699-1617
11.Borehole diameter:6 (ifl) tab.j nr iulectilon Welk ONi.Y: [it,addition to sending true fonn:to the address in
- 24nabove- Aso submit a cop}, ofjtbis form will in-30 days of-completion of Heil
12.WM'coustnlctiou a1etbod BSA/Core/Air Construction to the follofiing: I
(i-c.�ugcc loran•,cable direct push ctc_)
Division of Water Rcsourwcs;Underground injection Control i'tvtirafit,
FOR RATER SUPPLY WELLS ONLY: 1636 Mail Scn•ice Center,Raleigh;NC 27699-1636
24c.For Water Supp.Iv sot Injection Welk:
[3a Yidd(gum) NIcthod of test
Also sulini t.oni cop_y�of this,furnf \r'ilhiu ;o days of completion of
13bl)ltiinfatiolrtvric: _ Amount: wcll constniction to the'counly licalth deparimcm of the count%,where
consimctcd.
F43rmGW-1 North Catalina fJ`pdro ciaofEnvilowncluandNattu lResoum.es—Divaionof\Ialerit(sotrm Revised..Augtnt_K113
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