GW1-2021-02705_Well Construction - GW1_20210527

WE C0NSLR_UCT10N RECORD FwtrtenmtuseottLY:
'ibis form can be and ror sinKiror aniltipk wets
1.Well Contractor Information:
X �Att Rtt FA
Stefan Smith FROM r Y
Aw Couhgtlor Nark IL M
3576A
NCWdlCanumorConifecationNuribea S�O[Tl tGAS1N or" itaiW Y URx NSF.R. Rcrb _.
mom, I TO .111MIKUYER THNI YMM MATERIAL
SAEDACCO Inc 0 fr. 3.5 n 4 tn. 40 PVC
Cedrp:tn!'Nomt 1 NW014URINC ...il ' '&W
YROM 122 MA:NLTt3R TIUCKKLRS I MAW MAL
2.Well Gnnshuetfon Permit*; fi. tt: ire.
I.iu araAwaraur,wo;w—io rt-.cmmty.stop,varimwe.Rardat dr) ft. h. 'TM
3.Well Use(Check welt tlse):
Water Supply Well: FR N TO D►ArrKTt?R IMsrvr T1HCtgY1tS$ srATKRr�t,
L9/1gtiCalltt►Tal C3Mvt»cipallPubtiG 3.5 it. 13.5 ft. 4 fry 020 40 PVC
ClGeatI nmul(Heatin&Cooling Super) Olkcsidrntial Water Supply(single) fi, In
Olndnstrial/ContmefeJai Masiden6il Water Supply(shard) &
FROM TO MATHR IIRmUcrkM_ rOD R Amomvr
Oln 'tiOII 0 ft. 2 ft. Sentonite Pour
Non-Water supply Well:
h.
omonitori 171itza�
Injectlon Well k r�
DisAvifer-lt omfge 0001I►"Vterltca iatia7► <, t'i<Nn
r
-FROM ATF'k4! F FI y1t
❑AgnikrSto jgcand:PccoxM OSatinityBarrier 2 t. 13.5 A. Sand 3
0AgWtfcr Tim ClStomm�ttCr Urn r o};C
0EXpC?imCatat Ttelmotogy OSobsidcnec Contml
tf�lRltlsTtet3° '>tt!>�iitlii�'r't�ici�3`ir�wettasy
OGeotheruml(Closed:Loop) t7Ttacer :FROM To RFscarrixox debt tear r w;afnca a ek
OGeodlenhal Waft • o Return MGther(Mi!12 under l<21 Remmits o 1t. 5 FL silt
5 rL 13.5 fl. PWR
4.Date Well(s)Completed: 3-18-2021 Wdl:ID#DP24
So.Well t oeation:
Charlotte Water tt. fL AA ��021
Facr7iiy�!YlrcnerN"M Feotniv wx CtCt Wtobte) 71
it
12701 Lancaster Hwy Pineville, NC 28134 Mecklenbur, tt, t1, i'st ► C..-
Pineville, NC, 28134 Pk-sieat;Addtcss.CiW:and Zip 2f,;
f onati> l�,rtptidcm','t5ralinn"No.tPtfit)
5b.Latitude and L, ngltadc in degrees/minutes/seconds or decimal deOve. 22.Cerf;ficatlon:
(if%e1tl"w"1d;4 ne Wotrg iS$rdrt6c-rd)
35.067984 N 80.874371 W 4/4/2021
SiWdi Content for Date
6.Is(amt}thenell(s}: :�Prrnmanetn or :OTempornry h yl giti�drit fam;l hrrrby r"rrtlfir fAtir flip nrlltsl 11w++rl cxnifrruere,d trr olfWrAfiirft
with I M NCAC 03C OM or.15A NCAC 02C;OM Well tonti thlon Smrader&a>td Ow a
7.Is this a repair to an odsdng well: Mee or ONo Corr of fish"Yawl has be m pr+n'kW torts„U mane►.
!f►hls is a rC�r,jltl adt befroa wrU ruevtrna lrtfc+nrrolion Cxlefa)Ae tee norwrr of lisp
repairt+dderAll rem&rj.WsrWLW"or.rM tlu h'Mek ofd5rr/orm 21.Site d*.Mm or addidoHhl Welldetalts:
Year n Use the bark of this page to provide addiolonat nail site derails or bell
8.Niumberof wells Constructed: ectstrue iondetaits. You gray also aaaeb udtfili nl pages if necessary.
for nnwl>ilalr 9rlfc�rton a novr»x�aer s� -rsu�lls O�VJ.Y n�fth rhr:srtrne t+a+ts�mlfavr.qua ca»
saYdrnu to r fovea tI13M[�7 A[ IN'1UMONS
9.Total well depth below land surface: 13.5 (n.) UL Fbr All Wells: ',Submit tWs form witbin 30 4M of coir►petion of well
For nrtlrfpie was fist tellalrptiis(ldi/irrCna fermty?ic l e7A0`oud Zip 1w) constnrct►on to The following
to.Statich ater Intl below top of CMIDZ (rt,} Bit islnn of VWater Rcsotmrtes,information Pm esesing Unit.
!/outer kwl isadmve cdaag,am'+" 16il'Mait Se",0C�trr.Raieig '$C 276".1617
It.Barthote diameter:8 (1n.) 24b.For inkctton V Sb- ONLY: 4h addition to sending de fomi to Me address in
24aabove. also subru t a copy of this forth.within 36 Ot of cor►tpletion of well
12-WCII eQflSiritCttafl ITIetllad: Sonic eonsmCtion'to tit follolt�lmg
li.e.Bn�G��•,abiq sliced���•t t
Dlvhlon of Water Resources.Undergr and Injection Controf FroMm.
FOR WATER SUPPLY W'GrLiS ONLY: 1636MaflSmiceC i nierRakto.NCI!6"4636 13a Yield(gplri} Method of test 2qk for Water sapptr&lnjCCtkM 1+c1U:
Also submit one Copy of this fonh ax11lin!30_daysof Cornoletion of
fat>.Distufectfon»� Ammmt: ivil ns an to the county hC ttfr dcpatlmrnt of the cosmh;nfiere
tructa
Form GW-t Noflb C-11=DgwUmM of Em imnmm and MnuW Rmw=-.i?ivkbn ofWatu Rrsottta5 hcnixd AA tst 2013
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