GW1--04636_Well Construction - GW1_20240809

WELL CONSTRUCTION RECORD For Internal(scONIV.
This form can be ducal for cin}tk of midlipk nc)Is
I.Well Contractor Information:
IL WATER ZONIS
Tyler Brown VRON .' to 1 OEM•RIPt ION
Viol('niii-o.rer Nam,: ft. ft.
4625A n, 1 ft.
NC Well GnatactorCemli,alx •,�� ItOUTER CASING(tor wrMiteud netts)OR LINER tit anpkcalik)
IRON ; TO MiMTTFR TRMKNTNS Mkrt Rtkl
SAEDACCO 0 f1. j 20 n. 1 ie. SCH-40 PVC
('oniran.N.,nr I Ii.INNER CASINGORI7)RlNG(Aeorhermalclared400p) _
IKON TO D7,01FTFR FOICA'F*t Mk t RIk)
2.Well construction Permit a: 70003214 R. ft. in.
Liu all upTrli,able urn p.rneo,f i.r.County.Mae.t anamv.Irraort el,.t - . .-------,
N. II.1 7.S('R[tN is.
3.Well Vie(check well rse): 1
Water Supply Well: FROM TO Mk%lT It MAMMY I tHICkNUNs I MAMMAL,
UAglkuh(tral dMtttiicipal,Arhllc 20 ft. 25 R. 1 'a. .010 'SCH-40 PVC
I IGeotttermal dleating.Cooling Supply) OResidental Water Supp12'(single) n. rt.
I 1Industrial+Comnicreial OResidential Water Supply(shared) 18'
1 PROMiMic TO , MATErUI. EMPLACEMENT METHOD&AMOUNT
❑1mg4ion R. R.
Non-Water Suppy Well:
R. R.
IC Mhnutonne ❑R Bowen ,.
Injection Well: H- R.
1 ..
❑,Agnifer Recharge OGroundwater Rcntediation I9.SANRIQAVRL PACK AlteDicaMl:1
PROM TO MAMMAL ItMM.A(YM►.NT'41100,
❑Aquifer Storage and RaoTety ❑Salirun Hamer ft. n.
El Aquifer Test ❑Stomm;Rcr Drainage 1 ft. ft.
ft.
❑ENpenmerual technology ❑Subsidence Control
is.DRILLING IA(:laltad,additional shcels if accessan)
❑GeothemraliClosedLoop) OTracer PROM To DEM:OPTION It.ir.h,ro„r....ur..-i.l.pr.inn..n'.rk.I
OGeothemal tileatingtooling Return) OOther lexplam under#21 Remarks) R' n.
ft. ft.
4.Date Well(*)Completed: 7-19-24 Welt If#B-2 H n. . ,f�U .� _,_ 4i.)
3a.Well Locating: ft. n. a G t� 5 2uR 24
Perry's Market n. n.
FocilinOn tier Namc Facility ID*(ifaoplicabki irh► �n- i rn. r-r.•-.efhr.'•a{t',*ir
n, ft. 1 CM C�,i
6727 Wilgrove Mint Hill Rd., Mint Hill, NC, 28227 H, I rt. I ,i
PM steal Address.Ctn.and Zip 21.
Mecklenburg
(' anlr Pare.1 h kalrfkatinn N.. 'PIN'
1
Sb.Latilnde and LNglettde is degrees/mitlartesfsecunds or decimal degrees: 22.('ertitikatNta:
of well Acid,one belong it sufficient)
N w
5J ~ 7/19/2024
Si .of Cert ��
Certified Well Contractor Oak
6.istarri the eellrs): -'Permanent or X'Iemporan
St Aigning Thu(orm,I herrht certrfs'Mar the refits)war(*err)a mrrru<red Its mvondamt-
.rM 1 54 NC.iC 02C.0/00 or 15.4 NCAC 02C.0200 Weil Comoro/toot Skln.lards anti rho u
7.Ls this a repair to an exictir well: LI tell or tS No <. .,..fop,,r.•-sled h,;,N..n l.,•ri•aled k,the urn rr.Mer.
if rho o 0 rrp.arri Ni aw tao.0.rill,aoirili rum ot/ornwi..n uu ar!r y.aiot ow thew o/the
repair under I21 remark,.waliun or cer the bark of Min forth. 23.Site diagram or additional well details:
You that use 11►e back of this page to pros sic additional well site details or well
8.Number of wells constructed: 1 constriction details. You Inas also attach additional pages it necessan.
For maleip$e nffr'Cr4on,w n mr-water sapplt wells ONLY with the same construction ,..a<...
iabinit one fem. SUBMITTAL LNSTUCTIONS
9.Total well deli&below lard iarrface: 25 (ft,l 244. For AU Wells: Submit this form within 111 days of completion of well
For.nrtlnpkt ell,list of!ATM,i)'difterrecirranapfr-#.7.0°'WJ'@loin construction to the followitrg-
IS.Static water les el licit to nip or Cacmne: (ft. Division of Water Resources,Information Processing I nit.
1617 Mail Service(cater,Raleigh,NC 17699-1617
li.Borehole diameter 2.25' i in.) 24b.For Inkction Went ONLY: In addition to sending the form to the address in
24a abuse. also submit a crops of this font( within :tO days of completion of well
12.Well coastructiim method:DPT :olstmelion to the idiom.ing.
tI C.miner.rota,,.cable.d1R[I rWal'.,IC I
Disision of Water Resources,l tide-ground Injection Control Program,
-
FOR W'1TER SUPRA IFFt I c ONI F:
1636 Mail Service Center.Rakich.\( 2 76 99-1636
11e.For Water Somali&Injection Welk
13a.Yield)emu) Method of lett:
Also submit oiw cops of this form n ittoo to das s of completion of
131r.Disinfection type: Amount: well constriction to the counts health department of the county where
constructed
Form GW-I North('aroliaa Depernwni of Em iiommet aid Natural Resources-Demon of Warr Resoiara Rc.ucd August 2,01