GW1-2023-02077_Well Construction - GW1_20230307

NVELL CONSTRu riON RECORD For h7cmaltlscONLY:.
TI is term can Lx vwi raT single or nwhipk wells
1.W l[.CantractorInformatiou:
-UIKUER ZONES .
Brian Ewing F"01N] VI DEWRIP1101i
!yell Cotilrcior l+amc ft. ft.
4240-B
NC NVc11 CotdtactorCenifLCstiunNiiwbei IS:.OUTER CASING triirhiutti-r_ikd ricflrl OR LINER(if u'►Ipcabk
FROM I 'ro PFAM TF.n THttKrE�s NtATEntAI.
SAEDACCO Inc 0 it. 6 ft. 1" in. SCH-40 PVC
C61111allyNamc. I&INNER CASING OR 3BING.owTjobviinaletuvd4oir(► '
FRO_SI I TO DUMETER 'rrnCLuN£SS MATERIAL
?;��c1t 4'onSU�tctiiin Qct slit kS 70003116 ft, Ft, hi.
f itr itll,: iliroblc wellpenni;a fix.C-olrnty.S'r.:c,l;rriawe,A.)`EC)C4 etr,.J ft.. fl
3.Welt Ijsc(ellgk well usc): 17:SCREEN
t N
Water Supply,Well: rM01 I TO BIAMM. .R I $1,0T5tr'r. I 7111CH4h55 I M1IATRUTAI,
L'Jtlgricultutal t .MLiklicip41MtbllC 6 ft, 16 ft, 1° io. 010 SCH-40 PVC
13GeothenRal(Heitinq�Coolio^'Supply) 011csidrntial Water Supply(single) ft. fL.
©9RdustriallCornnicmiA ❑Residentiat Water Supph,(shared) I&GROUT ..
FROM TO. MATERLAL I EMPLACE110T.51MI01)&A510UNT
Ellai pion h. fL
Non-Water SupplyWe.1l:
EdhlpniigrikR QRCLoN•cry
Injection Welt: ft. FL
MAgttiferRcgha%C ❑Gron-MTtaw R.ctncdi;iljon t9',SANWGHAVELPAC[{li(a 1 dicah[il"
vns►M yn �tAT1;Rrn1. F:ttNl.,►rr,Nr►;�'r±irr.I•nnu
❑AquifcrSCogtgc<atA Recovi:,ty ❑Salinity Ranier q R. 16 R. FILTER SAND # 2
❑Aquifer Test ❑Storm"'Mcr Dninagg
❑keperintr lal TMhntslogy [ISubsidcncc Contrat
20,DRILLINGLOG7anach additional0cc9 if r-CCL%i rsl
❑Geodtemutl(ClusedLoop) Mracer F?tOM TO D1r5CREPT1U1tt»br.UnWnc.r,s,44m�h n r.clal
❑&otheunal(Heaiing,Cooli ig Mum) ❑Oflwt(explain under 921 Retuaths) 0 it. 5 it, FILL SILT AND SAND
5 ft. 15 fL MOIST TO WET SILT/•CLAY
•I.Date W*11(�)Cangdeled: 2-7-23 1D#TMW-2
15 ft. 16 ft. WET SILTY SAND
$a;Well Location: (t. ft.
Space Craft (t, rL (�-• ,� ..,y
FacilifyrOn•ucrNarue Facility lT)n'(iEeppli:ablcy - '-?
R. (L
525 Parkwood Ave. Charlotte, NC 28206 Mecklenburg ft. fLMAR 0
Charlotte, NC, 28206 PlnsiealAddress.City..1(Pdbj3 21:REh1ARt{ti _
Mecklenburg 08304212 BENTONITE SEAL 1 TO 4' lfi A_„ ,;;;: "1 r'i:'- • '• •s ""'
;n
C'onulp harts]lih Initic lion Nu.(FIN)
Sb.•I.istihtdcand I,onglttulc in flt tresfminuteslsecontlsar dceimal ttcs rocs: 22.Certification-
(if V11 rsld,ow Ipb7PLtg is Sldl!�Lnd)
W Brian Ewin 2/14/2023
si.-®tui ofCcniried WcIl Coninctor _ Daic
6.Is(are)the NN•ell(s): ❑P'ennanent oe xTemporary
Hr signing rhir fonrr,.l frerrhr et rj?fv rhar the'mdJ(s J smy ftten:J vuenimaed hr.rcevrdmlce
4*4 15A)TAC MAW nr 1.SA NOIC 02C.0290 Well Constrie6e11 SrarNlareis and rlurr a
7.Is this a rejtaic fu an vkisting wclli Oyes or 'ENo ropygr"this recrinf br'4- bfcei(in-.ritled ro�lhr.civil«rr11e1r,
if Jl'1s ds rr relxtlr,fill r.V,r kix,Ivri well c'onym(Meja hijorawf:on rmc74tp(gbi dre'n2rare of rfie
re,­'r wrdcr 02)rcvnrrrks.scxrian or rm the lira•.-of rfUs form• 23:Site diagram Or additiount NveL1 details:
You may use the back of this page to provide additional well site dctails:or Isell
S.Number of wells coustntcted• 1 coustluction delalls. You play'a IS6altlacit udtlitional.(i:Iacs if oxessan.
For intdflple Jiejealon or uoa-n'arer rpll+Jy n'ells ONLY iNfli rhe snlrrecorrsrrrri(Iwr,ymt eeei
sdl rvdrone form. SUBMITTAL INSTUCTIONS
9.Total welt depth below land surface: 16 (ft.) �,rJL For All Wells: Subuut this fann within 3U days of completion of well
For nrlhlpfe wells list a9dephs ifdifrrrrnt levrall�fe-3@20'erru1.2@14W) Construction to the roiloniug:
19.Statie,water level below Lnll of casing: ((ti,) Division of Water ROuurces,Informatipn Prucessing Unit,
if wafer k'vJl J,dLave caal}ar,!ru'^+^ 161714LtiLSci vice Tenter,Ralciph,PVC 2769 9-16 17
11.Borehole diametcr.2.25 (in,) 24b.For Injy,egjRo UVSlls ONLY: In addition to sending the fomt to the address in
246 abbe. also submit a copy of this fotut within 3(f days of completion of mill
124 Well eonstniction mctbod:DRIVEN Construction to the follod'iner
(LC.811�U,ratan',cn01c;diMl push efe,}
D(visjtut of Water Rcsourccs,Uudcnhroulsd Injection Control Psograpl,
FOR WATER SUPPLY NVELLS ONLY 16361FGti1 Scrvice Center,Ralelgh,;NC 27699-1636
134t,Yield(}grog XvChod of test: 21c.For Water Supil}v&Injection Welbe.
Also submit one copy of this foini withitt 30.day'sofcompletiorlof
I3b.01sinra'tiun gpct Amount- wCll constructiath to the callnty liicalth dcpnnmcnt or the county N hem
constructcd.
Form GW-t XonlLCCrolijia r}CpaalRCn!a(Ea5'ir011llSCin Sltd NILilral Mour"s-Division or Wcllcr RaaLr= Revised AuguA1013