GW1-2021-00325_Well Construction - GW1_20210312

WELL CONSTRVCnON RECORD ForintcmdVscONLY•
Tbii-'arn can baand far s qlt or mulls wits
1.W411 Contractor Information:
Will Keyes R M d CRltrrlry
t*�dta�cadort+faria R., ti.
Yt. fl;
4220 A
NCWtHCbntmctorCcnitksflon+tsnnbcr 1 O °, Afit {t` Gniflidtir�tt�► stt tt a fb :`
FROM TO DIA:tTFM TMCKNTAS MAi IM.
SAEDACCO Inc 0 fL'. 8 fi 2" IA, schedule Opvc
tooltw%Narrtc 1""�I it�aN tteisersd�tYit+' >`
FROM TO p 7ttrrrgvFa MA71!:RIAL
L Wdt Construction Penult
140a11drpptlrqJ5lruvrlprMh;lir.t'rlUfltl,Sprso;tnridnr�,"rR Qirrr,l R, it, Ire
3.WdlJfse(d=k+wdhuse)-
Water Supply'Wdlc 'rROH, 0 A, ftt..-rx VOCKNM MATMA
DAgrictdtmal OMtmlcipo. Attbtic 8 it 23 ft. 2 tn. 10 schedule vc
OGeotltarmai MeatingtCooling Supply) allesidentiat Water Supply(single)
01ndustrialtCom"Mc+al MR*Od enual Water Stippt,-(sbatad) tatty ":
FROM T Tl RtnL ti1iPLAi f r rlurrnOD �itbCh*r
Olni [ion 0 M 4 A. Portland poured
Non-Water Supply Well: � IL _
MMonitod OReso�
injeettoa Well: f4 ft.
OAquifcr_Rcclt QGrouttdctfitefRett►ctlitlton 3 C. . t
Q fcr.Stora c and a2eGos I Salinity 13articr rR 1AYP,tti t. tuna MM M. n
$ vq 6 ft. 23 ft. sand 2a
13A(Mift:r Tcst OStornm�ater OMM,ge f n;
OEa nmcntni 7echnotog CStlb;idoom Control
ntrol
3d}�al t1 L } "Yrtacliittditlri>F1:.
t7Geodietmal(CloWLoop) 13Tracer FROM I TO lESM11MOF(atut i18roaM s��i+xtc N
OGtrotttermal fit a ReMM) 00ther "rtultdg#21 Remaft 0 ft. 23 ff. saporlite
ft, ft.
4.Date Well(t)Cotnpletcd: 2-4-2021 We111MdMW-13
Sm.Well Lneadan: fL n _
FwflhyVwmrNaw Far1MW M#{if Vpti=b)e) n. ft;
12701 Lancaster Hwy, Pineville, NC, 28134 ft: ft
I- f }s8ca1 Addnxs City and Zitf fit.RRt+1AltfcS. 7 7, — R.:. x _
CL
United States
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COOM " V� a ldcnlii`olieio Nn,(PIN)
5h.1A#i dcand,1.6ngitodelodcgmcofmirmtMtcc6ndsrordec'nm"d Pvm 22,Certifccattnn:
Or'Atli Wo,mK 1.*10(19 is Sid11&M)
35.066365 N -80.875821 W 2/8/2021
w�
si�tareofccWettCcritcreror Dec
6.Is(are)drewdI(s): MPermanenf or OTemporary 4 sivbw t4ls form.I h+err}y treO,thea tke»*!Ifni w tr(„v v)eownvaed in Ae nhwi e
r+ltlt 15A NCAC O?C`,OIM or dSA l3CAC Me,AMO Well Como*w tlon Smndards anrdtlr 4
7.Ls this to repair to-an existing well: OY4m or IMNo e+�+yc�rhi�re+rarrFkMrdxrrnpmiFr&+drn mttn»wr►.
Ifrhts it rt OWIft fill rest kW#'WV+UIVO earuMMM WOrffao W dMf r.MpfOi"the iwrart of ft
rr01rirte7tdiw 21 rr ar"srrtim ar.an ht bark of r ufarm 23.Site dtWam or additional wdl detalts.
You army use the back of this pap to provide additional n+dl site details erwill
8.I�ttmberof treks mttstrttrtrd: 1 conametion detaits. You may abw attach additional pa if oemsaty.
For mdOple Infeerkm or,rum-gofer str{dy wefts ONI V ufrA-rho wme Mnsg7rclFo¢r.w am
xafttatmeform CCitMM t111CTLImm
9.Total welt Qcptb below landsurface: 23 {f10 24a l`rfr All Wells: Siibfidt this Soft within 30 dogs of obigktiort of`t4vr11
For arcOplewrtlslisr all*p*rff di;ryerta{{r. ,L-3e2M*aM,a4-tfh) contsintctiont0 licfbtlming;
10.Static water level below"I of twinz 5' (tt.) Division of Water Itbauttet.Information Ptoecssinp.unit.,
tf Haller frM It,r 6OPt€dstspt,rant"3" 1617 MallStrricje CtntW.RoleW NC 376"-1617
t t.'linrehole diametct 6.25^ din.) 24b.For anfer E 5rllc ONLY: In addition to sending the form to flag addtws In
24aabbve_also submit a copy of this form within 30 days of coutpietion of ueli
12.Welt atnatrurdon mole d, sonic cmutmerian to ibe'rallo►inir.
(ic:suer rctaq-able d'"push,ck.)
1fhision of Water Resources,Visdergrennd Injection Control Progmu.
FOR WATER SUPFLYWICf..i.S:ONLY: 1636 MAR Service Center,Raleigh.YG376"463b
tan Yldd(gi►m) A7cttrod of test 24c.For Waw Sa lr&in radon'Wettr.
Also submit one copy of this form s�iltnn 30 day�sofcoitlplet on of
13b.Rlsinfemon type; Amount: moil construction to the county heabb delmamrnt of`(be county-s6 ae
constructed,
Fonn CsW-t Nonh Carolina Depanxnad of Wmim nt anti A}mwW Resowees-Division of Walerltemim Revised MOM 201.1