GW1-2022-10659_Well Construction - GW1_20221128

WELL.CONSTRUc rioN-RECORD Fur hrcmal use ONLv:
`Tlibbnncan W used fat.si»rfocr nurltipk nctls-• �\ j
1,Wal.Cantt:tctoiLtPorrimeiou:
�MAVATLRZONFS I
John Eisenman FROM I 'iri I DMCR91,110\
)Nell t'oiitnaor Q:;ame R: it. �'
4439 ft: fG i
NC Well CmuractorCcriif=gonNuarber t5:Ol7TERCeC5t11Gtl+ie`nihllFcrsedlreRs'ORIINER(if.ai tcabkl <.
FRO3i 'M METER TItlChrf.SS iTATERfAI.
SAEDACCO inc 0 ft. 15., it. 2" f rn: 8CH-40 PVC
Causgaarn Nauic• Cd:INNERCASINGOR:TUBING.(7i«"thetriltdct(ried.lna" ;
FROST I TO DL%RIFTER. TInCK.'YS5S- I MATERIAL
2.NW1CopstructirinPci'[irit#: 70002559 R, ft, in
Liri#fbigilirable rsrll pertaUt(ir,.Cafuitu,Sur:c,Variative.487/C4 60,
tt. a. in
• 3.w�ii fise tchcd:ircll list), '. :IZSCtIFEN
Water Supply Well. FRONT 1 7101 1 orAarn'r st sr,grstn; I T1ncKNESS uATURTAr,
©tSglitWtitral C11GItiniclp,•tG•Ptiblic 15 Yt: I30 ft.. 2^ in oio scH-4o PVC
Moothemntt(HwtiilglCooling stii)ply) bResidentiai SYatcrSupply(single) ft. I. it is
®litdust».11lCoumtcrcial ©RtsidentiaL WatacSuppn'(stntfcd) -18;CRt)UT•__ = _
FROST Ta- siATFRUL EMPLACESIMAIMlou&IAMOUvr
OitTi lion 0 'ft. 8 fl, Portland Pour
NgnAVatterSupplyWell:
dBlvfanloring C1Rtititarcty _
Injection Well: ft. to
QAquifcr i; giiarge Wrouiidnala Rentcdiatiou :49: ,NWGR,VELPACxfira i ilkAhte>',-
"-� - '�E+itt)31 TO --• 3fr%'rP,R1Ar. •BSINLACt\4EVT514:TnOn
❑AgnifccStoragc and RcctlrcTS' ❑Salinity 8ardCi 13 R. 30 ft. , sand #2
❑Alnifc�Test ❑Stornivv:ltcrl7rtggpc
CJlsspetintcntal TcchtioCogp. C]Sctb5idcsbcC C9rdtpl fin;IIRILLI\Q;'l t}G'tallaeh addllioriul sticCts if(rcccss(in1-
❑1eotitennat(Closed Loop) ❑Trjcer FRO31 I To DFSCTopr!O*X fuolSr.li;rrdncci.l!Mmck tr pe.giii"wa cm-)_
❑G:olltennal(NewinJCooliu2 Relutu) ❑Otter(explain uruler 421 Retuath's) 1 0 ;fL 30, ti,' Silt'/sand/clay
11-3-22 MW-12
4.1latte NVL'll(9j.Q,'9nll►lCled:• `%Veil ED#
- $at'W�1 Gtentlntii fL ft. � .,.o R� iq
Circle K 828 ft, ft,' NOV 2
-Fact)-ity,'Oi.tacrNaaue. Facility fUR'(9Eappiicnblc),
10329 Park Rd., .Charlotte, NC, 28210 ft. fG
.
Piry3icul'Aifdress:City�:airdZi� =yt:REntnRt;S�'. - .
Mecklenburg :Bentonite seal from 8�13'
Conttt} Parcel td JOSErC:ilicn No:(P4'vt)
sip,.Llititudc itnd 1.6ngtude in dcgrecs/minUtcs/seconds nr decimal degrees: 22.C'ertillcatitru•
(itaa I &t4,One l;w1mig ix'stdt iiew)
11/13/2022
Dale
6.iS(;tiC)lbC{Yell(s)* SlPentfaitent or ❑7CU1LIOrat} H�•si�nL�g t t,�r:�� (u�; sa y.�e F'�LcnsriucterP in;ccxarrmre
tiith Ut NOW 02C=x� , -1 „:r n 57k,02a)Mell('rnrsnr,rdnn Sron4drdsgndYbar4r
7,listhis a reOaic.fit an Edstitl;;udh ❑Vey tir ®Nil ropp�jrhis ireoiyf lirib fxcn ptrrrir&d(nilir.si%:l1 rnc,ier,
if lhl,'S'.lY tt lYpalr.fiU twat kRGlt71 1i'tfl c�aru-rtarctlon-LPfOrlta(IflOn and t.4p1a111-rho owwre of the I' '
relurirrarrlerH2f r�marks.rsrtian os an thea0 is -3.Site diagratuorddditional wetl detlils-
Yonause&batk
of this page 41iP10vide'addidonat tcell site details'Or rich
8.'1luatherof wellsc'onrimeted: 1 construction derails,.You inas atL g atraeliadditio»af.pages if hecess:uy.
Fort"alri/0It(fecalon ONLY arhhrbe same colrstrirel7ar,youi'ma S TRAfIT"fA .INSi'T .TlON4�
submit one fomr. -
9;Tot:tl-welt depth lwfo%c land surfUcei 30 (ffa 24a. For AU Wcilsi Subudi This fonn ivill d 30,daps of completion of%yell
FermaliipleWeldslisrol/depths**dif/rrrnll..roair,fe-,t�2(Xl'Rrui.2 l ) constmCtiontollic(oliciniuU:
10,Static water level delavv top of cusial;t 18 (D,� Division a1'Water Re5'aurees,lnfobtaitian Pnicessing QDit,
Ifmater level h tibove easira,we^+" 1G17 hLtiL.Scititecif�ntt r,Raleigh,SIC 27ti9J-1GL7
i. i
11.Borehole diameter.6„ (ia) .24h.Fnx:Fib ll n M115 ONLY: iln addition to•sending,ihe fomt to the addrM in
24iiabove, also'.sWntit a copy-of[his fatlu within 30 days-of completion of%well
12.Well crmstntcdon method:Air' Construction to the follovv°ine:
aug;s,iadary.cable diaect pasl4.ctc:)� -
Iilivlsiou of Water Reseurces,Undergtrouud[ttjecelou Control Proglailt,
FOR`ATERSIt'PPLY WELLS ONLY: 1636It A$crvlce'Ccntcr.Raleigh,NC 27699406
13a Ytdd( irn) t[ctliod of test: 24c.Ftir Wafer Snnni_v Xc[n�cctlnli-Wc[Cs:
Also sobtiiit o6e cds y of this,61111 %Yithiu 30'da)ysofcompletion.of
13b.DisinfectioD type*• amount: %veil consiniction_ to the caunly hcrilth department of the connh where
constricted.
Parnl G%V-L M/nh Cam11nl fkpapmero of Pnvironmcio ad Natur!Resources—Div'isloo of male R'Mo r= R?.VLwd August M1.1
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