GW1-2022-04889_Well Construction - GW1_20220525

r WELL CONSTRUCTION RECORD For imcmial Use ONLY:
r1,is form can M-used faT single or multiple•nclls
1.Well Contractor information:
I4.WATER ZONES
Stefan Smith FROM 'TO PRIC.RIFTIOY
t1'dtCort;mcterKatra� r1: rr.
3576A
NC Well ContrictorCenift<ati6aNturber ii.OUTFR CASING(For trtuhi-castd o'cils)OR LINER if a ticable)
FROM. .70 DIAMFTF,R.. ' T/ItC6�ESS' MATERIAL
SAEDACCO Inc 0 ft. 62 ft., 6 10 40 PVC
CauWaity Name 16.INNFR CASING OR TUBING 1 eat►rrraal ekrsed4uop
FROM- TO DUMETER• THICKNESS MATERUL'
2.\Yell Constivction Perini%N: 0 ft. 70 ft,: 2 11L 40 PVC
List trR rhpslicitblr%sill(i s rrili;(i:r Carmit Stdtr,lrririnncr,It�rg4ivl r aril ff. Ft. in
1.Wei lsse(cheek well use): 17.SCREEN
WutcrSupptv\Yell' FROM -1 TO nLWirmit sL0V147L. T111CH.INS .I MATERIAL
C1AgricultilraL L']hiunidipaVf)ibiic' 70 ft. 75 11•, 2 un, t)10 {40 PVC
©Geothermal(Hcatinr;Coolin£Supply) ❑Residential Water 50pply(sinE,lc) tii ( ft. in
QindustriallConlnicicial ❑Residential\VatcrSupoh%%(sharrd) 18.FROMRO�I To MATERUT EAfPL\CFMIIT�TCfiIOU&AMOU\T
❑iris ation 0 It.- 65 ft. Portland./Bei%�ts
Non-Waler Supply\Nell: ft. Ft.
monitoeing ❑Recover•
Injection Well: 71.: FL
QrinuifcfRcchargc ❑Groundsl ice Renicdiittion 19.SAND;GRAVELPAC6tir ,►stands
-FROST 70 .'. 11ATERIAI. F:TIPI,ACF:\IF.\T SrF7111111
❑Aquifer Storage ani R C1 0%en' 13Salinity Barrier 68- ft. 77 to. sand 2
❑AquiferTcst ❑5lornvvater Drama=c
ft. rt.
❑ExpCriencntalTcchnologc ❑Subsid-mcc ontrtrl
20.DRILLING LOG(0112cM additional suds If necessary)
❑Geodiennal-(Closed Loop) ❑Tr= FRONT To DESCRIPTT(1\Itvbr.6atdnc•.wa'n,cl:h air wa ilc.l
❑Gcothern331(Ileating,rCooliue Return) ❑0tlier tcxplain unA&r-tf21 ReulatlL,L
60 ft. 102 it. Rock
4:Date\Vell(s)Completed: 4-8-2022 Well iDdMN33B
n. ft.
Sa.Well l ocatiun: (L fc;
Facllil)zOrcrrrNartsc FacildpiD.(ifsppli:ablc) rt. H.
1824 Statesville.Avenue.Charlotte,. NC 28206 Aleckle, ft. rL
Charlotte, NC, 28206 Itrs• l4ddre5s Cit}'.andZip 21.REM1tARI{S
+� Casing set awhile ago and geo-physics done'
`"""t' MAY 2 °�` �'2�Iifocaiinis No,(PIN) as well
Sit.Latitude and Lo.ngitudc in dcl;nvs(minutes7sccouds or decimal degrees: 22 Certification:
(if a ell li<IJ;o,R I:,i,TOng k srdticknl)
\\` _
35.246951 �{i 80 �Si�SrrlQilA J:�i�V � _ 4/19/2022
"'' 'mom Sl;mr'• ofCchifrc�ti�;cllCantrxtor Date
6.1s(are)the well(s): XPennutent or ❑Temporarn' Ur elgning this ftd,n,Iherebr rrrrifc th at Ihs a'rlt7x)xvs(%rn•1 com7tucsed in tweanfrnre
n'itA 1 SA NG(C 02C,0hh9 or 15,11 NCAC 02C,0200 Well Con stri'minn Sraralanls ani rl,<rr a
7.Ls this a reiiair to an exisliny ii'clt:.. 0Yes: or 'MIND. rr��vjthir,rconi b isinrria pn>r,il d rn r�r,in 11 Lfint r.
if lhls It ri rrl�,fr,fiR air krrii,ir,,rill too,nrriiian[rtjnrn,zr'c,i imd replain rhr nararr ojrhr
,repiT rurderd 21 rcmarLyurfi©n or m die btxk oftlm form- 23.Site.diagram oradditiuout well dduilY:
You may.use the back of this page to,provide additional%sell site details or cell
8.1\umber of wells 6nstructed• construction deiiiik You
May also a[iach additional pages if nec: !tan.
For,nri,Ll t,i`giccrli,rl oeaxriYiirer n,Pplv.k'd404V1 I,r01 li the same co+rstrlrcriwt,}'<.a Can
sabmitane jams. SUBMITTAL INST(ICTIONS
9.Total►sell dcpA hel6rr land stiTlafe 75 (ft.) -24m For All Wells: Suhinii it"ft no within-30 tL•acs of completion of%%ell
For nuilsipk�icrOslisi all flepiksifdirrrenr(rrao,nrt••3@201Yc114l2@109) construction to the rollo%%ing:-
10.Static%s'ater level below top of casing. (ft.) W Vision of Water Ralourcct,Information Processing Unit,
!f nmtrr Ertl G above'rasing.rut'"+" 1617'A1ail scrs'ice Cctutcr,Raleigh,NC 27691 1617
11.Borehole diameter.6 (ir) tab.For Glitction Wells ONLY: in addition.to sending the form to ik address in
24a above. also subutit a.copy of this form within 30 days_of completion of a-01
12,\Yellronstn)ction method:BSA/core/Air constructions to the following:
4Lc..ug'r.rotary,cable.direct posh ctc.)
Division of Water Resources,Underground injection_Control Program,
FOR WATER SUPPLY\YELLS ONLY: 1636 Nind Setvim Center.Raleigh,NC 27699-1636
13a Yield(>?pmj Method of test: 24e.For Water Sit ply he injection WeRS:
Also subtirit one:copy of ibis fo
rut'ilhiu 30 days ofc6liplelionof
sccll construction to the county health department of the count)'whcrc
I31).Uisinfatior t,Pei Amour( ,
con5lnicicd,
Fanu GIV=t Nonh C uolint 0.pmtnlent of EncirOturcnt and Natur 1 Rewurces-Diviiion ofWatcr Resourms Rn'iscd Ail ust 2+)13