GW1-2021-00323_Well Construction - GW1_20210312

WELL CONSTRUCTION RECORD For lowmalt_iscON1.Y:
This form can lr:used rM'Sinrl-or Milliip]r+Veils
W I i
et�Contractor Information:
1141.NIATERZONIS .
Stefan Smith FROM 1 TO [IE;tiC'RlPllt)\
Wolf Coitricior Karns 29' ft. 30' h, Top of rock
3576A A. A.
NC.1Vcl]Conlrrcinr Ccnifilailioil Kim ber 15.OUTER CA:SfNG wens)'OR LINER fif a Iiry6k)
FROST TO 1uA�(F,TF1t Tu1CF-%Fi 3 WIN IAI. i
SAEDACCO Inc 0 ft. 20' rL 1" in. I SCH-40 PVC
Cauv a)iy Name KAKNER{ASING•OR TClBIN'G(wilivirm A&wd-1400
FROM TO DLA14IF.TER TFIICKNEM MATERIAL
2.Well Construction Pchuiit k: 70002840 ft. ft, ul
lest al,'r,•lr)7ik-ahlr well Penritr 1i.P.G7ifm4.-.31a.•r,Veiriarce,11yaci n err.t -m
ft. A. M.
3.R'dl Ise(chtxt:well tt ): lj?AC,RC'EN': ='
7N4'atcrSnpph•Well: I Fitom TO DIArttiTF,R +t$)T$l7W I I MATERIAL.
Ot'a kultural 1 20' R. 30, ft. 1" io• .016 SCH-40 PVC
0-Geothcrutal(Heating!(-ooling Sul?ph') 011vasideni5al Water Suppb'(single) , ft• rL
DindustriaUComnicrcial 0111csidcntial Wafer Supph•(sh;ltc'd) 18 GROLT:-
FROM 'Fo IflAft"imm I JEMPL.AC£MF_tiT\tETiIOD�C A�fOL11wT
❑ittieation ft. fL
Nan-Water Supply Well: rt. A.
RIVIonitorin ❑Rccm-cr} _
injection Well:
0Ag1)'rfcr Recharge E10roundnhicr Rcowdiartion r114.SANDIGRAYlL'PACh(if a'ritieal)te};'
FROM Tn MATFRUL, E.,IPI,ACF/1F%T N!"111)1)
❑Agnifcr Storrgc Iltd Recovery ❑S llinin s lrricr 18' A. 30' A. FILTER SAND #2
❑Agnifcr To ❑Storinwater Drlirtc gc ft. fl.
❑Exqpctimcntal To:hnolo.6,y ❑Subsidcncc Cor4ml
l 20.DRiI.UNG LOG(attach sdilhionat3taNslf neceacnr )-: 1
❑G;wtliem)al(Closed Ltwp) ❑Tr:lcer FROM Tp IDFS('RtPTIU\ftobr.hardncrs.�iil'nnAfr "ndre,tAC,i
❑Geodtetnral(Heatii%YLCoolipg Retum} 130ilter(txplaitt under#21 Reniad;s) 0 ft. 6' ft, Site trace fine sand
6' ft. 30, ft. PWR
4.Date 1Yc1.l(s)Completed: 9-21-2020 Welt ID#MW-1
n. n. PT-CM v m
5a.Weill Location: tt. rt.
Wendy's ft. ft. MAR t
Facilit}'i05vnerNa)ac FaeililyID# fapplicablc! "! ft. Pro„reSs jf19 V11�c1�
10729 Park Rd., Charlotte, NC, 28210 ft. A. [)�,rdR Section
I'Igsicu9 Address Citc.and Zip 21.RVUAXKS.
Mecklenburg 22119213 Temp well for ground water grab sample
('annN' Parcel rdoldificahon No.iF'IN1
510.Latitude and Lntrgftude in d&V- tWruinutvsrtccnnds or dMinal dcgrecs: 22.Certification:
I'if ne1F fxW..rxiu:L•a7oiie is firdlicRrd} •'y�
35.090760 N 80.869259
Si�ivtdo�ofCc.rfrcd Wdl Cownrlai Uaic
6.(stare)the well(s): 7Pennateent or 1t7Temlrorar2' Nr m',veirng thin fmrr.f fterrhr rrrfifs Thal Me weflrsl ivas f%irn,j crnuinfeled ire feev-46rire•
"*11 154!YCAC(W,I IM dr 15A NCAC( C,020.)111`rll(}Tiitp7h;iron Svindartls wiri rtari o
7.Is this a repair to an existing well: or Ire No )'wary(!i rhiv rr:onf has 1n•rvi jwwi h•rl rev)?w uvll innu'r,
!fn'tis ix a rrls:Hr,(i'i txN%ran:a iarllr'm!,r7nn liar!tnfinrA4:r e!n dr41 rsjdnin the!ina!re..f rfir
rq!ri�iarrler A_f rw!r¢rllts srr.-liexe Y.�I 0.q thl'hC!'k i!1 N145',farD1. 23.Site diallranl or additional well details:
You nrty use dr'back of this Alfa to provide additional well site details or'tell
S.Number of wells constructed: 1 Construction details. You tirmy also attach additional 1xigs if n vessary.
For rndfff4e).rfex'rh r m arxr-iixirrr))1('f/ Wdh Ofi'l.f 1001 rf4')rtmtrarsp'uefi(?$l. ;Tri wire
.%a6mit&m.forr), SUBMITTAL INCT IC:TIONS
9.Total Nell depth behniv land stofan_. 30 (ft.l 24a. For All Wells Submit this form within_19 days of contptction of well
For re!)hi,"lr mq'(!3 Kir all deplbi ifrlij.'efe t (11412R 100's construction to the follotein--:
10.Static water level below top of casing: 21 (It,) Division of Water Resources,Information fmccming(:nit.
If rrdtrr level is ehrwe rasia;r.am 1617 Mail Seffice Center,Raleigh,NC 2 7649-1 6 1 7
IL Borehole diameter.6.. (tn) 24b.For iuhrHon $Vclls ONLY: in addition to sending pie form to the address in
2-la above. also subinil a copy of this faun within 30 days of conipl'.4ion of well
12,Well co struction method: SSA construction to llte folloicin_e:
(i_e.auger.rrAary.cable.direct posh cIc:1
DiviAon of Water Resources,Underground Injection Control Program.
FOR WATER SU7PPLV YELLS ONLY': 1636 l/lail Service Center,Raleigh.NC 276'19.163C
132.Yield rgpm) Method of test, 24c.For Water Supply aR injection Yells:
Also submit one copy of this form within 30 days of complelion of
13b.Disinrktion hype:___..__....__----- Amount: wcll constriction to the county health dep:lltrucnl of the county wfrere
rown-mcd. V
Form GW-t Nonb Carlin Depanmelll bf Enkmotu sin and Mit oral Rewurces-Uir3sion of Water Reeawces Revised aVgW._ry'rl 1

March 4, 2021.
Information Management
Division of-Water Quality
1617 Mail Service Center
Raleigh,NC 27699-1617 ;
Subject Well Coristruction/Abandonment Records
Dear Information Management:
Enclosed are well construction/abandoninent records for the following locations:
Location Job# Date,
3678-3288"State Road 1524;Battleboro ,NC` 13445, 02/17/21
8036 Moncure Pittsborblbad;Moncure',NC 134727. 03/01/21
7098 Fox Court;-Gastonia, NG 13478 03%01/21
973_Rocky Ford Road;Reidsville,NC 13444 02/23/21
12701 Lancaster Highway;Pineville, NC .1,3439 02/08/21
921'Woodward Ave; Charlotte,NC 13442'. 02/19/2 i
-10729 Park Road; Charlotte,NC 13301 09/22/20REVISED.
Sincerely,
Karen Byer
SAEDACCO, Inc. '
Enclosure(s)
9088 Northfield Dr. • Fort Mill,SC29707 • www.saedacco.com ♦ [phone] ♦ Phone (803)'548-2180 •=Fax [phone]
South-Atlantic Environmental Drilling and Constr6ction'Co.