GW1--03123_Well Construction - GW1_20240522

WELL CONSTRUCTION RECORD For(normal Use ONLY:
Thu form can M used for smirk or mudtipk net,
1.Well Contractor lrtformatkln:
IL WATER ZONES
Stefan Smith TOON to OItSSC'RIPTION
Well C'orametor Name ft. it,
R, ft,
3576A _
NC Well Contractor Ccni1 t,on NumberIS.OUTER CASING(for emelli-cated wells)OR LINER(if Ikaek)
MOM TO ttlMlTFR TOKIO:TM NALTRIAI
SAEDACCO 0 R. 14 ft. 2 in. SCH-40 PVC
('ampam Nang If.INNIIRC�.ASINGORTURING meadclswed-lospl
FROM TO DIAMETER TUI(K FSS NA IF.RI Ai
2.Well Construction Permit II: 1000417 R. it. ie. -- —�—
List a0 applicable wrll permits fir.Carron'. .am. Varese'[,Nitaion etc.) -- -.._.__. .__..�._._.
R. R. rye•
3.%%ell I'm'trite&well use►: 17.SCRUM -
lt Ater Supph V.dl: VRON Ttl DIAMETER 5IO iNt T ar T111(1t NV111141.
UAgit�ulttital OMutnrclpal.PuhliC 14 ft. 29 R. 2 .010 SCH-40 PVC
i
(:]Geothermal II-bating/CoolingRipplII-bating/CoolingiRipply) OResidetxial Water Supply(single) fry R. in.)
s I
C]hidustria1 Commercial OResid nttal Water SupplyIL UT
(��) FROMGRO !O MATERIAL E\Erl.l(EMOIT METHOD&AMOUNT
El{motion It. ft
Non-Water Supply Well:
R. ft. —,
®Morutonne ❑Recover
Injection'WO: rl.. rt.
❑Aquifer Recharge OGrou dmatcr Remcdiation L la-s.l\D I.RA\'LL PACK lit alyrlicabici
`1kt1�i - 10 SistlStSI 1NIPIytt%n\TN1T1100
uikr Suxa c and Rceover ❑Salinity Barrier ______
8 12 ft, : 29 fry, Sand 2
❑Aquifer Tcsl 0Slommater Drainage
R.
❑Evpcnmcraal 7cehitologs ❑Subsidcncc Control
i lA1#&LIPIG LOG WM&alfillrYleArelsif acumen l
OGeothemal(Closed Loopt ❑Tracer PROM TO 0ES[TNPT1ON'valor.l.wrder..,wdww-I,II pr.er..w..rr.rk.
❑Ge tlterrral(F eatinJCooling Return) OOthet(explain under S21 Remarks) 0 R. 17 R. Silt
17 fit. 29 ft, Sandy silt
4.Date Wells)Cimpkled: 4-25-24 Well ID/TMW-1 . . - . . -..
ft. II.
5a well Location: ►t. I I. MAY '' 2, C 024
Metropolitan Redevelopment ft. rt.
Fades OnncrName Facrim IDS(if applicable! fry. ft !,lotion- I'`] a r,.',,,.. a!I.!I...*'•
1200 Metropolitan Ave., Charlotte, NC, 28204 R. fl, '
Plnsical Address.Cit..and Zip '
:1.RI:MARK.I'
Mecklenburg Bentonite seal from 10 to 12'
COmay Pre l ldk nl.f,C:d iou N.. I PI]I
5h.Latitude and Longitude in de1medini utes/seennds or decimal degrees: 22.('ertitkatien
lit ell held.one halms a 0Jl'ekll) _. r
35.211639 N 80.836017 Iq• !' / i ""' 4/30/2024
Signal. of Cc,tied Well Contractor Dale
6.Is tare)the nell(t): 'Permanent or mTtmperan tl,elgniaat Mu fam t Irrmin rrrryy Mai thr.rrO,..l was I wren c'r.rtaniard or accordance
with 1 SA NCAC O2C.0100 or 1 Sat,NCAC 02C,0200 Well(.',o ratn.ru Se uwlurd'rind rhwr a
7.Iva this a repair to an existing well: :Ycs or EINo rips of this rr con(has hem periled es the wr11 owner.
If Mb to e tepaer,fill is r i,,,wa w rli X rn»ow tarn ntfamwrttat am/r%pla nil tie rnrare of due
repair under Ill rewwarkr.rr,-rior,or.,n the hark of this fan... 23.Site diagram or additional well details:
You nun use the back of this page to provide additional well site details or well
8.Number of welly constructed: 1 consimction details. You may also attach additional pages if necessary.
for multipie rukrrlon,r,N,NI-w'nter rwppt,urlh ONLY wail Ow unSe rtwrsrrirrkwt tr.w aver,
vubrnir..,tr(orm. SUBMITTAI.INSTUCTIONS
9.Total well depth below land surface: 29 (NA 24a. Fur All Weller Submit this form within 11.1 days of completion of well
f,,r mwlripir wrOil lot an deprht if dtperrnr 1<aamrph'-ft.i`IRt'[awl iO fiat', construction to the following,-
Ill.Stalk water kvel below lip of easing: 19.8 (ItI Division of Water Resources,Information Processing l nit.
If Hake lerel h abort.r,on,' n e-. 1617 Mail Service('eater,Raleigh,NC 27699-1617
11.Borehole diameter:8.25" (in,) 24b.for lnjlrtion Wells ONLY: In addition to sending the form to the address in
24a abose. also submit a copy of this form within 10 days of conviction of well
12.Well ceotin.ctioe method:HSA couslruction to the following
it C.auger.roan.cable.dined push ctc.l
Division of Water Resources,IIndergnnend Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Serra ice(enter.Raleigh.SC 2 3t9')-16J6
24e.For Mater Supply R!nivelion Wells:
IJa.Yiaid Iglini) Method of test:
Also submit one copy of this faun 'Elton W day sofcompletionof
IJb-Disinfection ripe Amount: well constnution to the county health deportment of the county'where
constructed
Form GW-t None Carolta=Deprannren of Ens mown sot Natural Resources-Division of w.wcr Rnottrt:es Re,teed August Ili I1