GW1-2022-06955_Well Construction - GW1_20220722

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WELL CONSTRUCTION RECORD Fprtrumlusc'ONLY:
This form can be used for single or nuiltiplc%Vohs
1.Well 6utrletor Informatluu:
` 4AVATER.ZONFS
Stefan Smith FROM I To t►"CklMON
We)1CgrAradorNamU 18.49ft. 27 R, Groundwater
3576 ft. ft.
NC-Well Ce=ctarCcnifrobtion9mnbcr AS OUTERCCASING McautfieastdiwcHs10R1.WM11fa"'Iieabk
FRONT To DTAMETER THICKNI ESS 1VtATERTAL
SAtsDACCO Inc 0 f4 17 IL 21, 1 :ip. SCH-40 PVC
Cattgoty Naan 16AN`VER CA9NG ORIUBING kiwtherrmd dased-loa
FROM TO DC4UETEM- TEIICKIVESS MATERML
2.NVclt Construction IPeralit#: WM0301210; 70003022 ft. ft. is
Li041al01icab!ewdiprmrilffii:Comilp..Vale,.l1orlattre.Iry-e:d rl'rtc.)
It. ft. ita
3.Wc11.Usa(checl.%Seli Dsc): 17.SCREEN
Water Supply WL•!1: FROM TO OtAMETT;R' 'SLOTSM, T1nCKNT-S I MATERIAL
rJAgde{1lttttal DMAicipaliNb)ic 17 ft. 27 R. 2" ia' 610 SCH-40 PVC
DGeothermal(Heafinj'Cooling Supply) ®Residential Wafer Supply(single) ft. ft.
®IndustriallConwrcrcial ®Residential Water Supply.(shared) M GROEIT.
FROM - TO. MATERIAL EMPLICEM VINIUMODSAMOUVT
❑dull"noon 0 ft. 12 fL Portland Cement Tremie
Non7%tcrSupply Well:.
Monitoring dRecrnrr) ',ft. ft.
Iajectlon WqU:
Glr',tfnifcrl(ccliarge 0 tourid%vatcrRemcdiailon ',MSANDIGRAVELTACR(it irucAteY.
FROM TO NIATPRIAL rtMPIN%(:F:VEVTVr:TrIOu
C]Atprifcr-Startgc aixl Rccavet}' 17S�linity)35riicr 15 R. 27 ft. Sand #2 Pour
ElAquifcrUst pStammatcr aMt;.k,aao
'ti ft. ;
❑ENpcmncntal Technology ❑Strbsidsncc CoMMI.
1o2.DRILLING LOGInuach additioriatsheclf if iicccssmvl
17Geathernml(Closed Loop} ❑Trio a' FROM TO DFSCRIMON toobr.hatdnen xdYntck jyre4xgo iit,�dt l
ElGeodlenual(HeatinglCooling Return) 0011ter(explain under 021 Rematis) 0 ft. 0.7 ft. Concrete
0.7 ft.. 7 fL Clay rx C Ld t:a
4.Date.Well(s)Completed: 6-9-2022 Weal ID#MW-2 7
ft. 27 (L Silt p
5a,Well Lucati)n: fL jULu 2022
NRP Holdings, LLC N/A tG ft
FacdityjUwn:rNanae Facility Neiitappiiablc) InAoftAislion ►t)CODt Una
R. ft. Ii
.3934 Raleigh St., Charlotte, NC, .28206 ft.• ft
Physical rldd Ass Ckt am Zip -.21:RE6LMS'
Mecklenburg 09107202 3 foot bentonite seal from 12 to 15 feet
Counly Parcel Wnlifnralipn No,(Pk)
SIP,..i;;itifirde'arid I.tiitgitudc hi dcgrtcs/minatesJsec4rids or'dccimal dcgtres: 22.Certification.*
(tf iiell(W14,obe,l•woug iR gulliclo]4)
35.150677485 It 80.474854975 7/l/2022
Sigml ofCc:fled Well Conuactar Date
6.Is(are)the.well(s): X]Pertnameat or bTemporky
Ily si8niiig thin fomr,t herrt+y rertifr thrartlae nef!(sl awcr{prre)cuairntrrerf tit rrcxotY{ataer
pith 1 fr1 MAC 02C.D100 or ISA AICAC 02C.OZaP Well Constrarriotr Sramlards and fix t a
7.16.t[tia a ire pairto an.11tingwell: 13VO or KNn caatsofrHis rrcairliuisbeen pmsidtd rottii sat:lir.+rn,•r.
if tiMls'ds n liepalP,fill Ott triaiivt ti rU c vlutratctlah htforaamlott marl ranlalat rile rdamre of the
repsrir realer ty2l rernnrkssreiiva'oc out the LrxL.of rfiir farm 23.Site diAgrarn or additiottal well details:
You may use ti►e bacl of this page to pro%ide additional ivell site details or%sell
8.mmnherof wells cousl=ted: 1 collsauetion delaiLs. Yon may also attac[t additional pis if mcessary.
For ipxltlple li?Avi otr ar armi-grater snp jdy+rolls ONLY rrliir tiir same corrstructlaG ox edo
.wkatft one form. SUBMITTAL RVSTIIC'1TONS '
9.Toiul well depth below land surface. 27 —(ft.) 24a. For•All Wells:. Submit diis farm within 36 days of completion of is-ell
Formtldplewells'list off dlep alfdifr eht(exantpte-M200'mx1201097 construction to thefollo%ling:' I
10.Static water level Below top of CaLiiufr'. 18.49 9 A) Division of�Yater Res`ucce,4 Information Ptncessing Unit,
If iviver level is aboty�edi-0ag;im,•'+" 16t7&fait Service Center,Raleigh,NC 27699-1617
l f.Borehole diameter e•25° ([u,} 24b.>wnr Intirtinn'We[ta ONLY In addition to sending the famt to the address in
24a above.also submit a copy of;this fetru within.30 days of completion of well
12.Well construction method:HSA Lanstmction to the folloMag;
(Le.auger.rotary.cable direct plush.cic.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:' E636 blot[Service Center,Raleigh,NC 276"-1636
13a.Yield(Rpm) tYctiuod of test, 24e:For Water Supply&IRiecttna`Vc1Rv:
Also submit one cop}' of this foau%cidtin 30 days of completion of
136.Disinket[uu type: Amaunt• well construction to the calmly Health deparimcrat or the county whcre
eattsmutai. Iff
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Forma 011-1 Noah CamlWa DepattuLm of Eueirattttaeu and Naival Resources-Division of Walcr+Resau't- Revised A gust 2013