GW1-2021-02703_Well Construction - GW1_20210527

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WELL CONSTRU ON RECORD for ln&fml Use ONLY:
Thia ram can be used kff sii*or moltipk mum
t.Well Cnntrnctorinformati0n:
Stefan Smith FROM TO D trTlr)N
%Nmcll Corfteear N"*
3576A
NC ltclt ConvhdorCvnifecationNtes
3•ilUT1t. ( aran+►f!'" (eA `Ot;, v ,
FROM. TO nrAnrE"TrtR :rnrrlcnTM MATERrAr,
SASDACCO Inc 0 R. 7 tL 4 114. 40 PVC
Cnf*tre} ncnc 2 1!1' 3yR• tNC:- ti ltatdd
IRON! 70 DMAVt;T6it. I Trr MAW..MAL
2.Well Constmtixion Perrtiltlr:
ua all Awfirnblr arlrpe"Wis(ie.cmmt-star.Varinare.Nerven m»)
3.Wdl,Usc(checkwellow):
Water Supply Well: FROM TO '1DrA%f1K Tt I sr Tspss Tin} MATMAt.
DAgitultuM DM(inicipallPublic R: 17 M 4 hL 020 40 PVC
0(ieoftrmal(Healing/Cooling Supply) OResidentiul Wtftr Siippty(singgle) ft. R." lrr
Clhndusttiai/Comtnercial QResidential Water Suppl•-(shamd) B t�ROIFi .:
FROM. MATfDW. EAtPLA "M AttTrrrOD i;1 iouw
obvigstion 0 R. 5 114 Bentonite Pour
Non-Water Sopply well:
rt._ rr,
olylonoodog QRecov
Tit on well:
QAquiferRccharge' DdroundwaterRemvdiviio+l
QAgoiter$torage and Reco", QSitinity Barrier goo air rrlcrnt, RMPr AC'rM► n
5 R. 17 R. Sand 3
0AIptifer Tea DS(ommVer Onrin age
oExperimcntal Technology QSubsida cc Control
ld:]1Rti�it��T;06.1a3tse7ietiiilm6tt: ry a
ElGeodtemwil(Closed Imp) OTt cer FROM 'TO orrscarr"ON polot,11vtom,townmca n*e."tl
OCoothenml Heau o Rmm) m0dier(ftTlain under#41.Remaiks 0 R. 7 th silt
7 R. 17 (L PWR
4.D2tieWelt(s)gmp(eted: 3-15-2021 WdjlD#DPll
R. fG
Sa.Well UnAtion (L ft. e1
Charlotte Water R. fr. �.
Facliil}:ltynaerNaioe FounlyWN(if afromble) R. IL
12701 Lancaster. Hwy Pineville, NC 28134 Mecklenbur, R, fl. v 1�
Pineville, NC, 28134 PktlealA(Mms,aly:and 25p 2r3tthiAll�`R J
V
(btutdy Pmttt lowiftmtion No:(NN)
4b.i,atiAlde and IAngi(ude in degrcc0mloutestmeondsor"mal deo•Ccs: 22.Ctrtifiration:
(itutil fktd,one tatllotg is sidlie4w)
35.068438 N 80.874529 W 4/4/2021
Signet of WtdiContracmr -Disc
6.Is(are)theweil(s): aPermanent or ❑Temporary Ur slang thb fa m,7 hemby twnjf.Mai.the nWits)XV1(wear)eft fevemd 8rdwamim re
u4th lSA NCAC 02C AIM ar JSA NCAC 02C.M00 Nell+CairitiwWon Stnndmt)a and Owt o
7.Istbisa repair toin existing well: OVes or QNf► topyoftAh word har&mptmlrlydroj*wwllonmr.
tf rhh it o remdr.fill uW?kmuae msscV C6,usnKWM Wb"OAMomr and fa7rf41n She wwrnr of the
repeir under 021 rrman@rsnrtiam or for bark offhix form. 23.Site diagram or additional well details:
You may on the buck of this page to pw%ide a itional wSt site details or well
S.Nlimber of wells constroded: eonstmetlondetails. You may also attach additiawl pages if necessary.
Fo r nWiirde Inject)m,owman-n+aver'jWplyarils ONLY iathrhrmmrtgnsffsrrrtatr,_Wem
smWe ane fMM S1111MMAL II STUC DONS
9.Total well depth below land surfaces 17 {t►,) 24a. Por Ail Wtiht: Subnut this form within 30 lots of coftTledon of well
FormaftipJe wells Get 4114 AS#,diffeftm feremipt,-302m,M42@]W) cemstniction to the following;
i
10.Static water fevct below top of castor. {ft.) Division elf Water Resor rtet.Information ProcewnR Unit,
if nsatnr legal Is ObOkV edg a{,tux''+" 1617 Wit S&viee Center,Raldgp ,lV '27649-16i7
It.Borehole diameter:8 (in) 24b.For lni Wg!l LVelB ONLY: In addition to sending the farm to the address in
24aabove, also n6tuit-a copy of this&rm'within=0 do)-s of completion of well
I L Well cons"Cftn method. sonic construction to the followW:
(i.e.avgrv:rolary,rabfG dinrol postti etc:) Dh-blon of«'ster•Resonrem Undergr•oirnd JbJection Con til VmMm,
FORL WATER SUPPLY WELLS ONLY: 1636 Mall S40ce Center,Ralelgll.NC 276914636
13a.Vidd(gpm) Method of test 24e.LFor Water SaUlr&1010010 i`S'keth:
Also submit win eopy of this farm,w,idiin 10 daysofvoiWetion of
13b.Disinfection type: Anmunt: well con.5tnictiun to the county Wahht do rime nt of the county whew
constnactod,
Form G1V.l Nonh Carolina Uspmbrxntof Emimmmu wd tbwal Rcsowws--,J)h*1oao1`Wsttcr R Re%-bW MOM 2013