GW1-2022-04883_Well Construction - GW1_20220525

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WELL CONgRUCTION RECORD For lacrnalUsoONLY:
Thh formcan(�usd Corsingtc or rmdlip}c rcclls'
i
1.%1e11 Contractor'lufbrulation:
14.WATER ZONES
Stefan Smith FROM 10 DF:S(.HIPIIOM
1l'cltCgiaiapvrNans: n. rt. i
3576A
NC NW)Contractor Cetiifiation Nirnber 15.OUTER CASING(for IDuhi-eascd nells)OR LINER(if u tkable)
TRO\1 I TO uLl\IETfiR THICKNES5 MATERIAL
SAFDACCO Inc 0 ft. 78 «. 6 is 40 PVC
Coulmny Aanre 16.INNER CASING OR TUBING 4reorherma)clowd-tar t
FROM TO DL\\tETF.R! THICKNESS \L\TERIAL
Z.Well Gonstructinn Pci•fntt f;: 0 «. 115 ft. 2
id. 40 PVC
Liitirll a17 lirabl.:uellprrmia(r r.Cnuntc,Sr«:r,l'ariarxe,Jr�`tipat,rtra `
fb fl. in.—
3.4 it Gsc(chrel:iclIi sc): 17_S(:REEN
water Supply Well: FRosr I to DOWNIEn:R F1.(►TS17j 7111th-NINS I \IATFRIAl,.
UAgH:ultural MfunicipiW tlblic 115 ft. 120 ft: 2 is 010 40 PVC
OG Cot hemlal(IleatingZooling Supply) OResidcniial WatcrSupply(sinble) fI. fL
0 indtistrialfConlfnercial l]Rcsidontial Water Supply(sbarcd) 18.o ROtrr 10 s1ATeH1,1e — I E\IPLICE\1r_VT\IETII(OD&ANIOUNr
❑liripatiun 0 ft. 110 ft. Portland/Bete
Non-Wa(er Supilky Wdl:
�btoiitoring. C)Rcco\ry
Injection Well:
DAgtiifcr Recharge OGrouniicrl(cr ReWmediation 19.S.ANDIGRAYEL PACK lit r dieable)
' : FROM 10. '.: �,\L\TF:HI►L.[. E\IPIACE\(EAT
OAguifcr Storage and Rcco►-cy Emi inity Aarrici 113 ft. 122 «.- Sand 2
❑riuiferTcst ❑S.torniwilcrDrainage
rI. ff.
OEVctimcntal Tnhnology O5ubsidcricc Control
20,DRII.LiNC LOG]attach additional s'tsreu if neces,an l
OGeothemtal(Closed Loop) OTriect FRO\1 To DFSCRrtTIONreobr.�ar♦nca.vra'nkk/� sndn•.de.l
oGeothemtat(I leatinetCoolille Retum) DOther 4explain uitiler#21 Reularls)
75 ft. 130 ft. Rock
4.Date Wcll(s)Completed: 4-8-2022 W. cll_IDPMW44Ds
ft. fa
5a.1Weill Ovation: ft. rt:
Fa,_ilityoOivrrrNam, Facility lW"(ifaFpti=blc) ft. (t:
1824. Statesville Avenue .Charlotte,..NC 28206.Meckle,
Charlotte, -U Q20-6 3 P)nsical rtddttiss Cily:arrd Zip '21.REMARKS
r A Casing set awhile ago and'geo-physics done
Conniti• MAY 2 Z022 -Nice]hknlif caliou No:(FL\) as well
51►.1 atitirde ind In.ngii1ldc In dr(Ms/minptca/uconds or decimal degrees: 22.CcrtiTicatioD:
(i Belt rr`Id,ors.I W7mra i+ r b}Sgjgv� �tg'j g
�lr U ini15�1i �1 1 k702�8 1 ��' ��� - ...
35.47358 _ _4/19/2022
SILt>rrt mtlofCc..rficil ti�c11 Contractor Date
6.Is(arc)the\yCR(s); XPenttanent or OTemtwrati' Br signing ihir(i.rmr l hercb}'rrrtife that Gu nrl.'{xi nos(r;rrrj curly urfrted in«cronlrncr
ri•ith!Srl A'GtC O:C'!71A`7«r 15.1 NCAC 0:.'C A:09 llidl Corrstrei ticur Srurr:lards«nd rluit«
7.1%this a repair-to an eustin{nell: 171lcc Dr .$Gill: copypj(flit rernnl ha.s 1h-rri prgeitli d to 14e r,trllOwner.
1/ih(s ls'a rej rlr.fit(txn Cnolia vVell tore lbaien lnJorrl!'rirnr'tmJ.r l[(itlq i1w ewrtre r f rbe
rric(rut,Jrr921.rrrnarkesrrtionortmdi�htxL'.oji?wfirni: 23.Sitediag-ramurudditionatwelldetails: _ .
lbu se:may u Ilia baci,of this pad toiproyide additional well site details,or well
Number of welts ciiltitructed: eoltsttuctiou delails:;Youillay also alto eh addlliollal pab'eS If itzeessaty.
For rifultiJ..deGrfcrrioncirgr'1=haternipp+ reellsONLY'k0ril(fie same comiruetinn,YOPcep
saGnietbtrr jnrTn, SUBMITTAL INSTUCTiONS'
9.Total well depth belaIv-1and strrfac. 120 (ft.) 2•ta.. For All Wctls: Submil this fomt within 3U days of completion of$yell
For willriple i,ellt lisn71l t1ejihs fj dij'1 a•nr .1@ 100) construction to the folloning:
IU.Static water level below.lull of iasinR (fi(,p Un'ision Df�Vatcr Resouryerl Infltration'Prucessiiig Unit,
nYl 1 tPr level ti churY.rucia�•:use"
1617 Mail Sen'ice Center:Raleigh.NC 27699-1617
It.Borehole diameter.6 Ain.) 24b. nr injVSlinn;Vellc ONLY: in addition to sending thy,form to tlw addrm in
24aaboi'e. also subtnil:a copy of►hip folnl within 3o days of colilpletiorl.of:%'ell
12,Well ooustntction method:HSA/Core/Air coostruetion to the ioUoning:
(i.e.anger rctan',cnbtc.diced push etc.)
Dl'ision of Water Resources,Underground Injection Control Progratn,
FOR WATER SUPPLY(YELLS ONLY. 1636 Mall Semite ite Center.Raleigh,NC 17699-1636
!3a,Yield(gym) \lctifod of test 24c.For WalcrSuppiy&Injection Welts:
Abo'submit olle cm of this fonu i0hiu 0 days of completion of
13b.DisinCatiugtypct,. ,mount: well cominlction to the county health department of tlic-county whcrc
constructed.
f\\'alcr R�oc
Form GIV-I North Catalina U.^pdnnucut of Eaeirormrrd and Natural Resources-D_h•u ton ot� Rc�'iscd August 24 t3.