GW1-2021-02706_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD Forlrtenmltlso6NLY;
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1.Wdl Contractor Information:
o.. LO
Dylan Fierst FROM Vf*Mttn10v
AVotlContmomRam
4507-A h.
NC Well Con"or.Cenith*InMuriber MO ING-49 *011 OR �N Ncafile
FROM TO PTANIrri i . 7nACKNTM WINFERTAL
SABDACCO Inc 0 n. 10 ft. 1" in. SCH-40 PVC
Cnrnfrmytts n6:. XWOM MIXG i at f ed�
FROM TO I DiAWTBR I TIUC MT'SS I MATERIAL
2.Wdl t.on#MCrinn PCrnilt#: 70002870 (l. il. 1.
tin pll,appliruNr wrll permttx(&r:Caun)f,Sratn,Varfawr,]##Chart oc;7
h. n.
3.Wdi.ilsc(ci►cck well use):
Water Supply Wdl: FRO" I TO. DWIFTITIt . STAKS17Y 1 TRTCTCTTFSS VATMl L
DASi ultuTal OK-micipai/lTnilliC 10 ft, 25 n, 1" In 010 SC8-40 Prepack
Mothemrel(ReatiAgCooling Supply) DResidenfial.Water$appt}'(single)
olndusfrial(Cantrnffdal DRcsidential Water Snppip(shared)
FROM I To MATERMn. �M :Strnnneu it AMOU
Olnilmlion
Non-Water Supply Well:
®Monilorin Mom".
Injection Well: fL (L
QAgllifcr Rccba%t 0droundTlutcr Rewditition 9..5' Ii ,. f..
Fa AT raT, I p p!�fT1Ti1wtT I°r ,n
0Atlni1crS1omScandRaoNrty Milinit,Bartict 8 n. 25 ff. gravel'/sand #2
13AgItifcr Test OStornmzttcr Dmimgr
n: ft.
oSxperimcatal T=hnplog 0subsidmce Control
oGeothemni(Closed Imp) oTram ROM IGtixTo cl• liiNiho��cdaniTxTox�I Mhc�srlrr��gn�R ,� a9r
OGeoBrttnnal(Rn it ' olit Return) oOther(eigAain under#21 Re nxuks) (L rL
a. A.
4.Date Well(s)Convicted: 5/8/2021 WdIID#TM-4
+a.Well LQCAtIITn: (L fL �
BIN-GRAHAM LLC r►, h. n
Facgsi}•AO+vmrNnrx Facility TV#(ifapphuble) n.
4823 N. Graham St., Charlotte, NC, 28269 n. A. n�E�SI
P10ii=1 Add=.Ci(y.and Zip 2l- 'kltr6RKSr.. _ C,
Mecklenburg 04519101 Bentonite seal from 6-8'
ta:rnty t�redtdcln3ficlllonNa(W�)
Sb.l atitnde and 1,. ngltudc III dcg rmhnlrmtWcccrinds or decimal degrcsi 22.Cet4ifnotion:
(itwell tkkl;oic l.tlllAl !s srdticlt n►)
35.280255 -80.808059 Vl` 5/16/2021
Sigurh=orceitmw WC9 CaftIetor � Daec
6.Is(arc)1be•lwdl(9)4 t2csmanent or _Temporary XC afgWwg this foam,I Araby eerTyr Ihw thr%Wf(S3 rats 4wo*)&mtrmaed fitdCt*rddrirr
wirh IM XCAC 02C,(l M or154 NCAC MC OM Well Const W74Vr Smr4ar3sandilx»a
7.Is this a repair to an caning well Me$ or tfiNo twy o Ak mrar has hrmpim irlr tin 40 aril axner
ff ibis h a repair.fill!ar kwkw uxe1!eoasrmaloq Womwrian card rwfaht dw mrore of the
repair rinder6?l mmar#serum or m tlu bark of thin form. 23.Site diagram or atlditlonal well details:
You may use the-W&of this pape'to preAde aMli6atial Till site details or weell
S.Number of wells constructed: 1 construction delails. You may also onach additional pabes"if twoessat.
For ectiom or rum.4wer sWl+d"`wUi ONLY ntth the name oonsrruclkM"ram CC71}bt[TI AL.INC t'[ICTIMS
9.Total welt depth be(oiI land sud lice: 25 (It) Z4s. Por Alt Wcllk. Sublirlt Otis fann wiftn 30 dms of cotrrple:tlon of well
for ow(t lewetlsUsrnflefr ;itdef'e►ens(exemtph-303001 and2@107) Constntctionto the foaming:
10.Statte water Ith-tl bedew top of casing: {(;,) Division of Wottr Rewurr~te.Informstib"prottasing Unit.
tf urrrer kwrl IS Oba+e C4M'4g,OM"+" 1617 Mich Semite 6nfsx.Raido,NC''27641I-3617
11.Borehole diatnctet-3.25" (in.) 24b.,fir lotettlon We71c ONLY. {:in addition to sending the fame to the:tddn sin
24a abuse:.also submit a copy of.this form within 36 days of completion of iaril
12.NNdl ConStrn fro Intahod,DPT Collumetion to the followitkg:
(is.eases:rumry,able,diTecd posh.etc.)
Dhislon of Water R.elto irmbiUitde gbund Injection Control Frogram,
WWr FOR WATER SUPPLY ILLS ONLY: 1636 Mail S�'ice C6ter.Ra.WP,hiC 276"4636
134.Vidd(Spin) Method of tr t Uc.for Water'S Du-lx&'Noolori Welts:
Also submrt one cop} of On tone iithtn 30'da3's of coinpleion of
13b.Disinfectionhpe: Amrlant:, well conslnivion to ft cmmly health dcpa3tmctlt of the exntnt)nlTt;e
comnictod. i
FarmMV•t North CBrelinsDqmtmrntcfEmrtmnrmmgandtVomWResoarees-DhsknofNramrRmsus I Rc%•1sedAygt92013
4

i
WELL CONSTR11MON RECORD For Ink=l Use O y:
'[his Torncaa be and for singic of MWIiptonrfis
i
t.Wdl PtiDtraetor.IfdatYtiatton:
i�S3at17tlt: �
Dylan Pierst FR nrTo IA tP7tQ.
1810CarriiitaorN.inlc n'` �' 6
ft. (h
4507-A
NCWcfiCOunworCRnlftcationNumber OtTJEtt SIN rtikittiteasrdate (1iR a 8cili' =
FROM Im MADi:—Joe
Tfttt'rWM MA- R IAL
SAEDACCO Inc 0 fL 10 d. 1" SCE-40 PVC
Cempctrp Nazra€ NGAR" , ING .
FROM TO OtANW.TSR MfWKNIM I MATERIAL
2.Weil Constt VAon 1'erMltih. 70002870 ft. ti. h-
140 all owirotb fwuponfti s fi_a.Countp.Suter;Vorinrrr,Iq�s f rl etc:)'
'ii►.
3.Well Use(chedc welt use): Tills'
Water Supitty Welt: 'FROM TO DIANKM Sr ter I TSHOM L4S I A TfRIAL
OAgricultuml CJMntticipuillitttbllC 10 ft* 25 lt, 1° iJL olo SCE-40 Prepack
00001benwi(HeatingtCooling Supply) Mesidendal waterSuppby(sinve) R ft'
OlndustriallCDninwa:ial OResidential Water Sr W4—(shared) =.-
PIrOM
OR do
TO
MATMUL OfFLACFM? 1MOD&AHOUNT
0Ini don C
Non-Water Supply Well:
mmonitorin
ZD on Welt:
CAgtifrRccige ANAh
Pw M A. aAl. RMpr ,tFVT"W" D
QAqui1 r$tordgeAn4Rccovety Osslinity438mcf 8 IL, 25 . ft. gravel/sand #2
OAquKcr test OStottrm rter:ihafnagc
ft:
Mxperimcnial 7`cchnology OSnbsidc-m:c Coaaml tt.
3a::TaRnaJlatG< ` G Htliti�itiltft8i4 s'#tlnnia .x:; .,
OGeothernial(Closed Loop) OTraa:er FROM TO OW-RIMON(Wair.WOM Otuwu .., ewee
❑GeoQaermwl OlcathNLaot A. n.te tKt
ft. fi,
4.Date Wett(s)Completed: 5/8/2021 WdIM#TMN-3
ft, fL
SIL We"Location: n, n. p
SIN-GRAHAM LLC tI. ft. �—
i acili MunefNann £acilk IDN(ifoppliaibie) ft. ft.
4823 N. Graham St., Charlotte, NC, 28269 ft, n.
Ptolkil4ddrem City.mndZip 21v'
Mecklenburg 04519101 Hentonite seal from 6-8' p�^��500j;Otl
t.`imtall' lidtdgntM alionN6.(w)
5h.Latitud6ind Longttode in dcgr%xs1mimrtcs/sacond5irr decimal degtecs: 22.Certification:
ttf xtit fktd;or l:rrt►aa�ds grdfic�m)
35.279979 N -80.806798 W 5/16/2021
Sigm nt of Ccetftcd Well CoSnaemt Date
6.Is(are)the wdl(s): Oft manent or :OTemporary By s;rMs Wt A-M 1 hetebp d 1th,Mal sloe xr1N,s7 ors f,vEre1 cownteted fm&,#wvhmrr
WrA 15A NCAC 02C;f1M or LU NCAC 0247;03fJI Well CnnstmiWaii Sma4vds amd that a
7.hthlsaMpairtoanr>USting well: Oyes or WNo *e rnithlrrrorrla rlarrnnror&kolttnaitr.irlt ..
IfAls It 47 rep flit nsr frroirn wdf eorttrwi4m ig fommlo rand rMlain Me tmn+re of rAt
r elmir mmder#21 remarks sertlnn or on the rtrl;of this for a: -23.Site ft ram or additional we l details:-
You may use die barb of this page`to pro-7d6 additional nell site details or%-JI
8.Numbtrof v+elis constracted: 1 Constmetion detains. You may also a teach addidotmt panes if t>eccssary.
For r Wprami-tearer;rip+pJvxuiltONLYnsthdiewmeSUBconstraciloot,:cso+tEan $i AE-TNOFtIC770N
9.Total welt depth betotrland sutftm 25 {n 2aa P r A[I WAIm."Submit this foam within Sit dayt,of cotnpMion of mill
For misWew(lsfisrofidg) r7pdrderrmtermc, tea tfo»fAtl`aW20t1'kl'j cownxtionto the follonins:
10.Static rater level bdOW top of casing: ({L) Division of Water Reconrres,Information Proesslsinr Unit,
ljwater Wei itdbwIv cvgq1 we"+" 1617 mail Service Gx1#er.Rltdgtt,NC276094617
i,
It.Da»rJtole diamctel 3.2 5. (tn) 24b.Fbl jp;(agp ff-dh ONLY ;Jit addition to sending Me form to the addnas in
24a ab6ve. also submit a copy of This form within 36 days of completion of ivdl
12.Well construction Method:DPT construction to the fbilolving:
tie:agrgv rotary;cable dLvdVasttcte.) f: .
Division of Water Ftrsou reessiUrlderground tnjecilorf Contrail Ftvgram,
FO)t WATER SUPPLY WELES ONLY: 1636 Mail Service C¢nter,Raleigh,NC 276"4636
13a lidd( ►m) Method of teat: Zoe. for gate.SOME Re tnioetto"Wdts.
Also submit one cop) of his fonh ivithin'3A da3i of comoletion of
tab.t)ix4nfeclinn Amount: w,ot1 construction o the county heattA dd�xrmnaari of the count}•w•bue
constm.cted.. i
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