GW1-2021-03346_Well Construction - GW1_20210603

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6
a •ELL CONSTRUCTION RECORD For Ime mlUseONl-Y: I
This fo m cast be owd fay Or&or mWtiolc u°eits
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1.Well Cantrnctor information:
Brian Ewing FRttH itr d 9ttt'titlY
iy`Eticomr aer>;ame 1Y ft.
ft. (1. 3
4240-B
NC Well Cclr maorCertifumtturaNimber J SRO-Iftlt}fisK-etefitt�eurETERAMA
WRo�t TrR aTAarlt'rt4tt TtItCR'S�5S titATCPtAt.
SAEDACCO Inc 0 tL 5 ft. 2" ttl, SCE-40 PVC
Crm4tui)(tiataitt FROM TO dta1NITER d lblt
,lrCwltitl+l WOW, i 'i(tr"ft�ift
TmrV"itES3 I1tATERtAL
2.Weil[:onstruethrn Permit#; 700002858 h
hL
list all applioubjr M-it frr-amJ1r fir.l"+xr vr_.5tbre.t iariawr,11ftard z em.I ft. fi, 4 �►
X Well Use(check Well ase}: .
WaterSopltlg'itiT�l; YRO:tt TO PG4;•t�'r8tt '$td7t5tL1' 'ft'It Ti'rT�'3 tr°tA'i`6Rtali.
DAgirkid t ml t hglltticiptllfPttblic 5 ft. 20 A; 2- is .010 SCH-40 I PVC
Qfettherinal(fieatitacoolitrg supply-i OResidetltial Water 5upp4`tsiAggle) ft. fL ip•
I3ludustriaifCormuerial QResideu(W Water Supply(slutre l) FROM TO ` 3rtAT&RtAL Etrtt l 14t�57 3WMC D.4 AMOUNT„
❑hri ition 0 It, 3 (L PORTLAND POURED
Noo-Waiter Supply Well;
®fv4ttAitraiiAr; QR4�Cat>r -
tojectiall Well., t
0Agnif4erRccharsm f.90roundntltcr Rcinediati4at
Q u*r'& c and R=oven' QSalinity tumor 4 � FILTER
� � 4 R. 20 ft, SILTED SAND # 2
DAiluifcrTot DMorirm`aterDmivaw it,
00gar6mentalTcchootogi 13 Subsidence i;orrarol
i�W-77
OGeothentud.(Clused Loop) ❑Trdcet FROM To OffiCRUrnON'fteiirr.tiiirdh iksLll* ` t ! T`f
t7Geothenual Return) 00thet in aMer 021 Retoa&-) 0 ft, 15 4, FILL SAND/SILT MOIST TO WET
y 15 ft. 20 ft. WET CLAY SANDY
4.Date Wetl(sp Completed: 5-13-21 Weil 1D#MW-4 ft. (L
5a.Well Location. f4 tt p „�-
CA Body Shop t ft.
Faal ty-10Aocr blow, FacT -1M of gilicuble)
548 West 32nd St., Charlotte, NC, 28206 tt. R.
Pinsnal Addrum(1y-;inif Zip 2 i€lsAfia! r tTi
Mecklenburg BENTONITE SEAL 3 TO 4e QV11-, i
�� 1 �cLt;011
f 4tealy Ptreot 141gmiftcitt is No.[PIN')
5b.Latitude and Longitude in degrcesd'minuter lreeonds or decimal dq_pvm 22.Certifieation:
Ofiadl fwid mtt WA-10ty ifi xrdliiieid)
Ewi n 5/24/2021
SignaWM of&Ai W Wdl Coutfaeusa r
6.is(Am)the Helitx)t $Permanent or :DTeumrrarc' Or ad nrnc Jhi JFtr.er.?.fro rrh? rrijs rduy the at-04s irmy i mrre.)cyntrnwMd AT.r:•avrrkaace
it wh a A 4CAC r)'{'•s'RW rar 154"VOIC OX 1)10)lt`el'i cl-mrirrace(off srog rran4 widd rdkti it
7.is tWN a n`pair to an txi4rting vvell. -OVts or ZNO r,Tj o. diXi word data br"P'fi l+asrvir&`rt rtr ihr'ur2aowner.
1frtt4'catrPrrcrr,ftl4...t+OA'1114t;rfre tifformric..Rfsrahxaitaineketa.tore'�fdie
rep--rir iordfer 021 rmirarJt srh.J�xt ,r mr the bork of this j'rxni. 23 Site diagram or additional well detmb-
You ma-arse the back of this pap to provide additional wV-ll site details or it-ell
8.Nombty of wells consitucted: 1 construi iarr details. You mat'abo Attach additional pages if owessar}.
Ff,r,raetriajr irzree'riaNi:.at ofm-rtritx r iuppih iaeidt ONLY-o rTi rasp sawn eo#bYliri`rJ w }on;i'diP
sti_=atar'm f.Mi. St1BM1TTAL.iNS'irIMMONS
9.Total n dt depth bed land surfaetn 20 ifl i 242. For Ail Wells: Subta t this faint%;Ahm 10 d t),s of completion of Hell
For roe dr4tir wdrf Iisr R a der'shr ffd*re•,i.fc:rrrr!>xln :i(� t?ta`a4d zoi,1&9`y tsAStAtCti9n to Ow following:
10.Static water level hel awn top Of casing: {It.) Division of Water 11ts6u Aces,information ProceWng Lena..
11»anti drat d is+edwve rri€ira2;tam"{ 1617 lfia#t Senice(;enter.tiideigh.?(C 216'99-1617
11.Bombole diameter.8,. (in.) 24b.Eon inieedon Wc11Re ONLY;` in addition to sending the farm to the address in
Ua abow. also skinit a cop* of tiriss form within 10 days of completion of tti.il
iZ.Wcll rt tttrrlion ttteth€dt BORED construction to the following:
4 i.e.augr.mwra .cable.distort posit cw-t Division of Water Resources.Itnderg"uud Injection Control Program,
FOR WATER SLFFI if WELLS ONLY' 1636 Mail Service Ctuttr:Raleigh,NC 2769*1636
eetb A t
13a.Yioid(Lpm) 4letlrrad of rest . 14c -For Water Suggl� nti►n Wells::
Also subAirt one call- of this form uithi t 30 dikys of comphM ion of
13h.t1i#infeCtinu t+r Amount well com(nictinn to the comim t colth de: rimcni of true county'where
F4sm u-1 NotabCalciumEhWwxwofE;i iwaiixitr:etaivgiiratRtuawm--es--DivnioraoftVateriRemates tRcrtmtd.AUVAlsl:l