GW1-2021-02709_Well Construction - GW1_20210527

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WELL CONSTRUCTION RECORD Farlttt¢rtmltlsct3NLv:
Th6 formcan W aced for sJngk or naliiple actin
I
1.Well Contractor Information:
tag zxl
Stefan Smith IrROM 10 PRSCRIV110114
%V401 Coahmdor Nam R. M f
R. ft.
3576A
NG Wc1lCotrtmdorCcnificetioul4tatt�cr I OtTYF.R
FROM, I TO 01A1mtYTRn TnICiG17&S MAIMAI.
SABDACCO Inc 0 fl• 5 (t. 4 40 PVC
la.
CaMmyNoate f. TtitDR• Gr {
FROM TO 910111F, TIITCI NFB3 I MATrli1A1.
2.Well canshuetlon Permit A; ft. ft.
lilt ut)app irrs6Je tilt prrm3rs(.'r.Cmaty.Sam,Variancr.11ftCd4n rtr.)
3.Wdl Use(ettcck wdl use): t7 >
WNW Supply Well: FROM "M 111049TF.R 1y JOT6nW1 Pail MATRRtAL
OAgrtcultural O1 mftipat(ithlic 5 It. 15 h. 4 in. 1 020 140 PVC
D(kothermal(Heating/Cooling Supply) OR(sidential Water Supply(single) ft, tt. In
OlodustriwComRxncial DResidential Water Supply(sba ed)
VT4LJuM TO MATEREAL niTF ICEMM METHOD A AMOUNT
obligation 0 ft.- 3 ft. Bentonite Pour
Ilan-Water Supply WOM IL
Omonitorin Oitet om
Injection well: R. R.
OGroundwater Remedlation ttt' . 3 r.
OAgnifer Recharge FROM TO WIATHRIM. ri 1�1T t r11 n
OAgaifc►StonitgcAnd =4DV ty OS.glinityfiaMin 3 t 15 t1. Sand 3
(3Aquifer Tcst DStornmater braima:
R. ft.
OlEwuttmcrital TcchnotoSt OSubsidericc Coitml,
30,:lARti`3�t1�D67iifiiiCM'"'- oael; stf'"'
OGeott nal(Closed
( .Loop.) t771ttcct FROM D crmn>tlox talur Ienw . sarcmex
❑CreotheanaltEieati 1CooJi Return) MOther Lex&in under#21Reotaft o ft. s fi. silt
5 It. 15 Q. PWR
4.Date Well(s)Completed4. 3-15-2021 Wdl,]D#DP10t1, t9
Stt. \'dllatept n: m• A.
Charlotte water
Facility0crterName Facilih-IDN(if aplaIk4k)
s n�J
12701 Lancaster Hwy Pineville, NC 28134 Mecklenbur,
Pineville, NC, 28134 P*sicolAddn'ss.all..AZip ; v
3 t lf`Af 717ttiS''.';
C60atp PAtix9 ldemificatieu N'4,(M)
5h.Latitodc and t ongitodc in dcgrmOmitnites/sceendsor dedmal degrem 22.Certir"tion:
O atelllkid,acretaOoflSIssrctttekfn)
35.068522 80.874509 W 4/4/2021 .
Sigmt afCe. tad Well ContBrc)or ;Daac
G.is(arc)the tiseii(s); aB+Permllnettt or L17'cmparar}' /tn-4smng iRt juryk 1 hrreiby.rnih.rht?t slu.mri4s)W'"furry)teat elm In aeti ardfanK
40h 15A ATCAC 03C.Off or.15A ARCAC MC AM RIO Cwwmcrloa Standards and Av a
7.Is thLs a repair to au cttirting well., OVe<c or ONo imc of this"word horbecm PPMOr l M rt+r aryl mtwrr.
If this he uvU emonmPon i4omtetion and expfaht*e mrwrr of rhr
ngsair o rt dry'p27 rrmerks s r cyiera or rxa the hrprk of tl4ir form. 23.Sitt dlWam or additional well detalls:
You may use the bast of this page io pmiid:additional well site details of w'eii
B.Number of wells constmcted: construction details. You may also ottach additional pogft if owessary.
For muNpIr)tit/erAmi or erxt-d ale+rtp*uw1h ONLY u4th fir aatne mnstttirctlon,you e+taa
submftarujrorm Su]�h.rnALIN3"t'tit DONS
9.Totalweittlepth below land surfilo 15 (i),) Z4a. Far All Wells: Submit this:form within 30 dr completion of ntiil
Fur malrlalr xx 4ls lair ref)rinpa s a+d cans/exarraPt.3�1 'aru!? 104t} constntenon to f following.
10.Static water let'el below top of casing" (ft,) Division of Water Raopttim lnfortn Lion Pateong Unit,
t/'natrrtram)hahoyratlaituxr"+" t6171Nafl5cniceCimterItah lyblC216➢9Ib13
t 1.Borehole diameter:s (in.) 24b.}err inicctintt Wel)c ONLY:i In addition to sending the form to ftaddress in
24a above. also submit a copy of ft ibrm within 30 days of completion of wt'li
12.Well construction metbod: sonic construction to the Mowing,
(i.e.supt:mmty.table;direct push ck.)
Dtm:ision of Water Remorces.Wndergmund Injection ControlPtogram,
J FOR.WATER SUPPLY`W LSONLY: 1636 Mall Service Center Rn9eigit.NC276"4636
t3a Yidd(gptn) dt4cthod of rr 24c For Water SRpltlr& nieallnn Wells:
Also submit one copy of this form +oythin'30 daps of Completion of
13b.Disinfection type: Amount- nfiil construction to the county hcNA departmcm of the counh where
consmacted..
Form CW-t Nonh Camllns Dqwb"of EwtionrDmd and&u W Rewumcs-,D-hslon oMlstcri(eww n Rn'iged AtCDst 2013

MELL CONSTR1.IMON:RECORD 17irclnferimithcUNty.
This f"can be ost:d far sink or ntnllipie%as
1.Wd[Contraetor 16forimation:
!t.'1+IA3lt ,fiA _
Stefan Smith FROM TO 014
1V41 c000now N-Aat ft. ft,
3576A
NCWdlCcnmmrCCt11firw oaNtmsbt7 #S:,F1t21 tth4StI4GF ifr 1ti�eafititri�tA�IOR ' pcab
FROM I TO Pt;A:Ivmlt TntCKNFM MATERIAL.
SABDACCO Inc 0 ft, 5 R. 4 in. 40 PVC
Cem{su�yN'a+nc GAR:AIMING' +t46ited4
FROM To —WIA—AIFTM I TntCWFM MAIX1110#41L
2.Wdt Cnn.OMC lnn Permit#;
fist ol(npplimwe w u prrmiis(i r.cmntk.Smar•%Irian,Ifter ort fir.) fl.
3.Wdl.Use(ctwk dluse):
7-77.77.
Water Supply Well:
FROM TO ])IAAiKM S1 '61M. -"11 $' JM:MIAi.
ClAgt1S7111RII0l 1:llVfl111icipalli'Id11ic 5 R. 15 f1. 4 la 020 40 PVC
OGeotbemvl(HeetinglCoolang Supply) CdResidelttial Water-Supply(sinsk) n it i
DindusuisManuneodal Oltesidential Water-Supply FROM.(stoIM) m
70 ,irfATLRUI. EtElIr1AC1G.'MIVt4'ME7TIOn fi AM tTi.T
Oftliga6on 0 R, 3 R. Bentonite Pour
Nora-Water Supply Nell:
OMonitorin QRs:coti ft. ft
Injection Well: rt R.
QAquifcrRccbige I3G'ioundlctiwRemediation ,
FR + tATPRtAM; IPr +rYT fT) n
OAtittifer Stomp and Rowvvy OStilinhy Bonier 3 R. is ft. Sand 3
OAgoifcrTest OStommaterbinimSe
R: R.
Olrxpirimental Ttchnolor,,v OSubsideatccCoMol
ttARtfAJI•ft1' (1.ifiiickdidrlifiot+srt3lrecftftileessa
❑Gtoothenlml(Closed.Loop) OTrneer FROM I TODBSCft+rlt0 C tebr As x ithvets rM i
O(koflemtal ti iC-ooli Rettlm mOtba(ex inunderd211kttawks) 0 ft.. 5 fL Silt
5 R, 15 iL PWR
4.Dale Well($)CamplWA: 3-16-2021 Wdl D#DP5
n: rL
SR.%Veil Locathin:
J
Charlotte Water
Facllii}rYlno:r Name Fac7ify tAi((ifatgpiicablcl
ft. ri. Y 2
12701 Lancaster Hwy Pineville, NC 28134 Mecklenbur, (. n, VlIli
Pineville, NC, 28134 PhyskslAddmss.City.and Zip
2aR . nOM
gut . .,,.
f.aotshp PArCc7 tdetilit�rilipnNO,( )
:5b.T.initi+de and I.1ingttude in dcF+rc,Flminute rAcconds or decimal degreW' 22.ikt+4ifxaHon;
tft sett old.we lAftrs is s1dfitkd)
35.068394 N 80.874243 W 4/4/2021
:i1 of, tieif Well ContweAor Date
6.Is(arc)dle rttii(s}: Permanent or OTemporarp
fi+n fa+m r�+b)'iFttif4 tkrldsr xrl!(y)lass fx►�reiamtttuned in dwi-orsim er
with i f A NCAC OTC Al09 ar(SA NCAC i UC.t M Weft Constrr den Strtrtctarrla and tW a
9.is thli a repair to an existing Irtil Met or ONo Copy offAh nvord h(s bem ptai hw to dw W ilavmsr,
1f thts it a repair,fill mtbt,ak+a iMl c~nlrnlaa!*nn*06n tmd oxeaht Ow nonwe oft he
n-W r snider dal reruns 8erdan or.txr Ar biwk of this farm. 23.Site diagram or additional well detaIN:
Yon;may we tire'IM&of this page to`jlmside additional well site details of mill
8.Numbcrof wells constructed: conswction details. You may also attach additional pages if imcessety.
For muNpie ihfeetW of non-uwre�Vr4,r wells ONLY with dir.same constnrtcAm you c+orJ
su6mdersu form. ►SI1B111fi i TAI (p]5MUCTIONS
9.Total welt depth below land surfaces 15 (n.) ZAa. Por All Will
Submit(iris;fool+within 30 days of cof Tletion of iftil
Far mW,Ople 4vUs for aU dephs 4'dtlterent(example-3@2Af)'trod 2i J4V) WnStntCtion to ft f9DOWing,
10.Static.h'ater legit belelts top of taxing: (R,) DIASIl not Rater Res trees,Information Psocessinp'llnft,
!f x+utt!r keel 8 Ob ve edtigR,.asse +" 1617 Mail S&viee C I�cn. tri.Raleigh,KC 276"-1+617
11.'Bor&otc diameter:8 (in,) 24b.rgr Lll e)>?,&M ONLY: to addition to sending the four to the-address in
24a abovL also submit a copy of this fbnn u9thin 30 days of completion of ut11
12.N8r+dl eonstruedon method: Sonic construction to the following:
ti.e.au�n,torsi}•,mole;difed posh etc.) �.
Dh'Ision of Rater RtsovrcmjViadtrgiinind lojcelion ContM Program,
FOR.WATER SIIPPLY`'WELLS ONLY: 16361V1sil S�ioe Center.Raleigh'NC 276➢4636
Ox.Ytdd(gpm) Method of test
zsc Por Wattx Sn 11r wjlc in�cetion,�Ve1(r
Also submit one copy of this fonn tt•itbin'-3h daysoiCompletion of
13b.LlWof&don type. Amount- hell conswiction to the county bcplih dcpaitmcant of the could),when:
cOtt5tttlGtOd. �
Fail GW-t Nonh Carotins Depwumnlof£as ronmad roil NstoralRewutecs-.13itiystos al Qt�sirr Ries Rc%1wd AL&d2013
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WELLCONSTRUCTION RECORD po�lraemalusci)Nty: I
'fiiis;form can beosed for mangle or tmdtigk%TVs
i.Wdt Contmetor tutormat)on:
Stefan Smith FR hl TO ORSCRtP110.
W0 Coerttatcretr Name D ft.
3576A M.1. 00 (� rlrrsoniKasrdm R�
R, (L i.
NC Well CbnnworCcnifkalbon Naanber <lc�b
FROM I TO DfA4tFTRR TR MATERIAL
SASDACCO Inc 0 (L 5 (t. 4 ln. 40 PVC
Coa":fty'Namc # ,lfV7 t. IJ aR IItG Oimfs 7# Aa
rOM TO DUMLTER TRTCr4NM " MATBRUL
2.Nydl Constr o"lon permit w: fG tt, Iri
fitsoPoppikifiNeurfflarrnafts liar:Cawq,State.Varionre.7rter&n ear.)
ff. ft. `itt
3.Wd).13sc(ehcck well a;cs•), _, .
Water Supply Well: ay TO I?A11977R suo� rrs itllf- MATRRTAt,.
DAsricdltural bmunicipai ftlic s It, is ft. 4 in. 020 40 PVC
C3Gco(benwl(fkating/C o ing Supply) DR midentiai Water Supply(iiigle)
01ndusnial/Commercial DResidential Water Supply(ftmd) 18� Rt
FROM I To MATERM3 Eb"LACEMF*.T MEif1OD tL AMOYIti'i
❑lrri tioo 0 ft. 3 M Bentonite Pour
Non-enter Sopply'Well:
Qtulotritorin bR�r h fG
Tnje 011 Well:
OAquiferRecharge 00tuund"terReftaistion yg>
❑Aquifcr Storage and Rocotety ❑Salinity Barrier Pa tATYRtAG PMPt A rYrrot. n
3 R.- is A. Sand 3
0Agnifer 7`c'at Wtommitcr Ortttr.agc
R,.. fl.
OF-xKdmcntoi Technvloa D$Ubsidzncc Contra
3fir-1fRitMNd-WCr7atiiieM`relitNt ovii A3Atvi¢cessar4
❑Geaotimnal(Closed Loop) t]3'racer FRODt 170 D$SC3?P11ox Itow oftelm
0GeothennA tit Eooti eRetum) mOdw ti under 021Remarb-s) 0 (L s rt. Silt
5 ft. is B. PWR
4.Date Well($)Completed: 3-16-2021 WdlM#DP21
it. (4
54.Wdl l.ocatttfn: (G
Charlotte water (t tt
F9cUk1y OavncrNnnv Facirdy W#(farpplicablc7021
12701 Lancaster Bevy Pineville, NC 28134 Mecklenbur, fi..
Pineville, NC, 28134 ftiiWAddmsL Cjiy:wd lip art a.
t entttj> Parse iO:Riitietttlnn go,(PIN)
5h.L*ftde and,Ungituric in degnecOminutes/seconds or dedmal degrees: 22,Ctrtil-inn:
Orwell(kld.wee laft"s is$10ftekni)
35.068007 l' 80.874452 W __ 4/4/2021
Sig Date
6.1s(arc)the+tie1l(S): aPerntattent or t3Temporary. By.siohk'hit from I hereby t*fwy fhrd.the"*joy)ww 4o")tonffrirered br 0Nw hf'*er
with ISA KCAC OX Afm or 15A NCAC lr1C.Ol'Oli Well Caratm rd m Smrt larch And AW a
7.Lt thtc a repair to an exlvfing well: oYes or 13No ['ttlt_r of rhis word h tsberw rum ed rn 4w sarfluamrr.
1f;*k4 o rrPdr'fiU carArwKra wit ennnnmrim lottw ian 4md expfalae dee uarwe of fir
retwir'mxlrr b3l,rmorlsmvfi m or nm the Dian r jdriforo 23.'Site dlagmrn or additional well detalLn
You may use the baa,of this page 10 provide additional ttvd1 site details of ts'eil
S.Number of welts cotistmotd: construction details. You may also aft dh adiitional patpes f necessany.
For ml#oe,trt/eerkaat or stwi-wer WrOy urfis ONLY nfth dir wme consttwsAw.�,4K4.M
aai8aiuttxaejWrrn SIMMMALiNSTUf">7 ONS
9.Total wdl depth belawlandsnrfae 15 (R.) 24a Por Aft Wells: Sublmt Qns'fann vilhin 30 days of completion of Atli
Forntcirfplr rfltGstnll 6rljdl�trexerlerawrfe-t4'dtJO'pnd?�It711; construction to(be folioning,
10.Stsde water level belotn op of+easing (R,) Division of Water tttsoiartea.infarmstlon 1Procewng Unit,
1f,otter 1~1 if ahme edaetix&w"'4 1617 Mitil Sanioe C�df&.Raleigh,KC 27649-1e 17
11,Boreihotc diameter:8 (ia) tab.FOE lnitxtlon Wells ONL Y: :b addition to sending ft form to the address in
24aabtne- alto submit a of this form within 30 dat 3 of completion of ticeli
12.Well conshvictlon method: Sonic ccnutmetion to the follo+hV:
(i.e.sniper.rotary.cable dirat pash cis.)
Dhision of Water Retoarce&indergrr ttnd Injection Control Program,
FOR WATER SUPiPLY'1TLLSONLLY- 1636 Mail Saba`+Centre.Raleigh.NC 17699.1636
13a.!Add(gpm) Method of tee iic.:1?or Water Sap2Ig&ldaqlora wah
A)so submit one copy of this fonir mthin 30 das'sof Completion of
13b.Dis)nfetction ty An►outtt well constriction to the counh'he lih dcpamncnt of the county where
i:DnslTMteted� I i
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Falm G1V-t North Cmolin a D.^pn=xW of Emirnume a and WmndRewwws-.tinision ofl'trater Rom Raised At gul2013
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WELL CONSTRiJMOK REQ()RD For inttmai Use ONLY:
'lltu form can be Used for-sirlgk or mrcttiple wrlis
i.Well Contractor.lnfortnathon:
Q +21z�R:
Stefan Smith FROM T P G1elartt)x
\94I Corrtdt cw Nana ft. ft. p
3576A
NC%11ComractorCeitifianio"Murbrr S.at7illdtC (J AM Dt er.'ier edw'tits:0ltl 1e
FROM. TD OTAMi?TF;it TBTCKtiR.53 ]NATCRIAI.
SAEDACCO Inc 0 ft 5 ft- 4 ta. 40 PVC
cmitnanyNanre 0.'' AASING'R; INC. CI a
FROM TO DIAMFTEit i TIRCIMTM i MA7T.RUL
2.Wadi Canstr action Permit*: rt rL
fur&11 nppfiraHr w U pry W {r r.Cawitu.Starr,Varin e.himdat ete.1
3.Wdl,Usc(check well a sc>:
Water Suppty Well: frROM To I I TArtoTSR STAT 11% T111Ck70W MArl3tuA1.
DAgdCultutah CJli unieipalmublic 5 ft, 15 fl. 4 11L 020 40 PVC
DGeotl banal(Heating)Cooling Supply) DResidetttial Water Supply(single)
C)industriallCwmercial OResidentait Water Supply(ftrnd) 11i 49RO07.
FROM 7O FIVATMUL iM1111ACEMENT 117MOD R AM PM
Olni `lion 0 ft. 3 ft. Bentonite Pour
Non-Water Supply Well:
0Monit9n2 ORtxoti
Injection Well: 0. (u
t7AgtriterRcch r Q(roundwi tRemediation tSAA
AN '" +t
. - QR M - A9'IIRFAt, pl,l►t,T7.1i}1T 1 _.._
QAqu*r Storage and Rtaco rW OSalinity Barrier15 ft. Sand 3
0A®nifer Tee AStomm*Cr 13rainas,C
OExperimcnial TcehnolM O$ubsidxrrcc Cottttal
-10,I)RHAMA .i,G'liiieCM iBi[itio»wY tReLlSAfautcess,'
OGeothennal Closed
( Loop) o1'raar FRo.r To nascRrmoN cs»r,heMn er;tu+atfx 15 . efts
oGooffiennal ftatinKoollys Return) 00ther'(explainunder#21Rema*s) 0 rt 5 tL Silt
5 fr. 15 % PWR
4.Date Weli(s)Completed: 3-16-2021 Wdl)D#DP22
n rL
Sa Weal Location: (t. rc �. ..,�
Charlotte Water
Foi1ityA)wocrMum Fwilih,IDN of WplizWe) 9
n. ff. y
12701 Lancaster Hwy Pineville, NC 28134 Mecklenbur, ft. tl. n r.rCa�StllUXI
Pineville, NC, 28134 P?WskalAddren,Caly.mWZip 2t RlC x i
�y.
Cower na+tY hurninotion No,(PIN)
Sh.l ntitudc.and i ongitude in dcgives4minuteske6nds or decimal degrees: 22.Certiiieation-
Of pelt field,one Wong is mdnektd)
35.068007 N 80.874375 W 4/4/2021
Signet of fiat WtU ConiTactnt Daft
6.Is(are)thewell($)* ZPerrnancat or D3'ernporary >; n erltr of form,t hero*-rerr#,v Mdt thr vtWits)+xis rwrtrl evaurnirrrd to wroMariee
with I SA NCAC 02C,U1{Xl o►15A#CAC 02C.02b0 Well Coxor erdw Stawfardi and hunt a
7.b this a repair to in ciisting well: OV s or ❑Nn ce>r+rafthu.erortrhrtsdm+i pre t t Mrlsr+irtt rni� r.
!f rhta fr a rrjwifr;jltl vnr,C+Hvraa wtrA t•+>�anmrfem ii�`oneretien oaf erpPafn du arnrwrr e+f fir
rejair under d2.1 rrr wAs stwAin anon the tarn*r jrblx form, 23.Site diagram or additional well..Malts:
You may use the back of this page to procyde additional nyAl site detaiis or well
8.Number of wells constructed: C0nsuucti0n4ictail9. You MAY also r!uaeb additional pages if rnxrssaw.
For artath#e lirtrrrk)nvr earn-nurser uW*w1h 0A11.V nfrA die wmt ao»strurr1m.,voatm
",bow ene form StMITTAL.iTVC'T{_H`T1071S'
9.Total waft.depth below land surface: 15 ffq Zia For All Wells: Submit this Moen Aiilrin 30 flays of completion of well
For MOIAPln wells listrrl40F]ai{d*rent(exrmfl'?-J@2011`ead2@100') COn5tnicti4nto the:fotlon•Igr, i
10.Static water Ir<Mt below top of caslDr, (ft.)
Division of Water Resourits.Information Pntessing Unit,
if+aritrr tetra Is obove edaPnp kte"+" 1617 Mail Semite Onicr,Rateiafr.NC276D 4617
It.lDor ehote diameter.8 tin.) 24b.For ONLY: �n addition to sending the farm to ft address in
24a abd%v. also submit OL Copy of Ellis torte cx itlun 30 41 of completion of Aeon)
3E.V4rdlcoustrpction:method. Sonic eensmetionto the loilotvistg:
(i.e.Opt romry;atilt ditea p tisli.ctc.)
Dh`Lcion of Water Resourem Underground Injection Control Program,
FOR WATER SUPPLY NVELLS ONLY: 1636 Mail Sch ice Center,Raleigh,NC 27899-1636
138.Viedd(gpm) Method of test: �for Wafter SR�plr do frtjacttion YWeIN ,
Also submit one copy of this font lrtt)nn 30 fts ofcompletion of
13b.Distnfection type: Amount well constniction to the count}bcnhh depa trnart of thr carnly w here
constrtacted, I
i
Form G%V-t Norih Carotins Dq ftnc-w of Emimivneat and NamW tttsowm-.Division orwaiff t'o r Revised ALVA 2013