GW1-2022-10661_Well Construction - GW1_20221128

WE:LL:COP+fS'i'RuenON RECORD F&[MenO iise DNLY:.
This form cafi tac used fm single or ndtipk wills
1.Welt.Coutrnctor Information:
'`tJAVATER ZONFS.
John Eisenman FROM TSa MiCRIMON
�l'r1ICurMredorl�tanlC Rr it, I �
4439
NGWcll Counactor CcriiIlcdion Nunat er '?i5::0[ITER CASING"(fui aiultt ea ed'aietlsl'OR LiNE R t1f.a'i'pcablc)'
FROM' 1 1m DtAtItETraa THICKNESS h1ATERIAL
SAEDACCO Inc 0 tl... 15 fL' 2' I 'ia: SCH-40 PVC
tbn5pmyN�aaft. =MANNER-CASING OR:TUBING(gtockermiitCwkd40W)'� '
FROM TO _ DUMETER MCKNESS I SIATERIAL
2.Wdl Canstr7tctirin['cra»t : 70002559 ft. It. •in, -
Lirtaillr.�7icabfrurjlprnru:ifcr..Cnaiiary.,Sta!e,Ua►iaaer,/nJarOn�lrf¢./ ft,` ft, Eae.
3.Wc16:iSso(chrcicsicll tisu); 17:SCREEN .
Water SupplyW�al: FROM TO nrAMISTa:R StOT817s; THICKNi 9 MATF.Rru,
DAgricultural (11VftltllClpaUi'ttblic: 15' ft. 30 R, 2^ in .610 SCH-40 PVC
®Gcotltemral{HeatiDgl�oolitt Stipp(}) ®ltes'idcntia[Rrater Supply'(single) fr'
OhidusftiWouintcrcial ®ResidentialA%rater;Suppl (stracd') -t3zCROUT z,...
FROM TO. HATERUL t E%fPLACEIlEVThFunioDLAIIOUNT.'
❑hri ition 0 it. 8 . ft; Portland Pour
Noti-Water SuP11ly WOW
6d1v4ontcyrinG .. C][tc�atitt}• fl. fl:
r
In 000 well:
l7ARHifcrRcchargc c3drduiidmucrR614alion 1v svvo;t:R�vEt ewcxt;rn��uc,t,fr1
'FROM To- MATMAL •R�aP4Ait5\IY'.�i'MF:rttntr
I]Aildifcr St and Rccn ca}'. []Salinity 13 ti 4 - 13' R. 30 ft, Sand #2 "
oAni0crT6t ❑§1.& tii;atcrlini q* rL. tL
❑Ryatsdnuntat'icclanoto '. MSRhsid.nccNwrol
2n;DRILLINL GLOG7attuehadditional shMs7if naessair"t•1
Ot.;Mhennal((lased Lpapj OTreeer FROM• . TO DPSCMPTIO\lmtin hnrslacH 5r 4Y,�sk 7�ere:Nr.1
OCroothenital(HeotinplCoolingRewin) ElOtlier(explain under,#21RetuarPs) 0' It, so 7L Silt/sand/clay
4.Date Welt(s)'Couipleled: 11-3-22 -Well i)#Mw-14 n.' fL ! �" °" �t. ., •�c
$� �v��l Ltieaatinn: fL -A. i ' NUV S 2022
Circle K 828
FicililyXI-wncrNamG Fk ft)-109(ifappJfcabtej ` ,r .
i Gir.Qir-OG
10329 Park Rd., Charlotte, NC, 28210 ft. rL
P11)tk l Addross City'ah Zip KS
Mecklenburg Bentonite seal from 8-1,3!
Cr)nuty Parcel hkjilirvu wipnNo.(01N) '
L ittituitc and t,un>;14uk in dcchiutl atcfatm, 22.C'crtillcation.-
{icir�nr�w;u,r;t:itnougi�sidrekraj .. .. -
11/13/2022
Late
' 6.Is(:are)th0vell(s): XPcnuanent or oTemporary By er'•gnr'r hir far,r r:fix !`:il�s'w�,`•s ;5i w7�i a xva}iiu[7erP Ar,dcxorrlancti"
ii'!rh 13,t N.CdC 03G.'t�' t^a�ri�.:dC t?:[7,7 t1i'lJCnrrsrrr,aiat Stara7arrtagnrl ifnr<r .
7.h tltlx it rejoaii to an eziitia-Nvellr t7YL`r {ir EVip calir fdiirircr;nl wifirsa pawl, r6ihr wfimrrirr,
If rhlsftnrrpnlr.fillcrukrrriii�aai'�llrarutrarcrlamlrtfdnruarlon,mAra�faJnnc�rpa¢rrepfrhe '� -
reraalr«arlrrb121 rcmarL+'.scciimi ar avr the back of rhls•fornL - 23:Site diagram or additional well defalil3:
You nia}'use tUe back of this page ro provideaddifional well site diitails:or niell
8.Numberef ivells eoastrwed: 1 cotlsuuction deiaits. You itwiv als6'atlaeit additional pages if ne6ssaiiy.
Per reaafdpfe iidwdr n iraon=u'wer supply wells O,VLY n'lr/f rhe.owe eommirfieir,y�par two �
sabmlrone form. auN 11TTAL.iN aIL ONS'
9:Total sel!depth betoai land surface:• 30 2U,Fnr All Wells: Siibndt dais fann within 30 days of.edutpledon of well
For'*04lpkirellslisrirlldepthslfdiftrrensfexwi�*-.i@a(a.9'aru1.2mlaw) constmctiontorlicfoltooing:
10.Static Water level.fielow top of casing 18 (�,} Division of Water 1ic�iiurccs,In6irmatiun Processing Unit,.
Ijarmrr let'r7 b bhori edd' ,iisr"f" 1G17 RIaiLScn'icc Ccni&,Raleigh,NC•27699-1617
11,i3nrelrotc diameter.6" (io} tab.For ltiftetlart Wcllc OVE,Yc Yit addition to sending,ttte form to the address in
24aabost:.also sub»nit a copy'of this fanii within 30 dms'of completion of well
12,Well construction method,Air eonstiuction to the followine:
{i c.augci rot u}'.,cnbl disat push cec:} Divislon df Water Ri'sdnrcu.U'adergrouitd hijection Control PrOgrAm,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 27699.1636
131,Yicid(gji i) 3[ctliod pf test• 2!c Ror Water Su slily. [njectioit.�Yct[s:.
- Also submit one copy of this.fdnD f within 30_days of completion.of
fib.Disintictiun tyres Amount: "well constmetion to the county heal7h department of the comity whor>
const;wwd.
Farm Gt%r-t NnnhCatolina El.-•pattutcait.ofEoylrottaucNaadYntntalRosourccs-Diti'sIDDOfSV3terR(--Gtn Rcviscd.Atgtnt:1013.
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