GW1-2021-02712_Well Construction - GW1_20210527

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WELL CONSTRUCTION RECORD ��l v5cor�l�v: r
'mt form an be owdfar sirsk oM rnldivk IWIS
1.Well Conttador Information: �
Ia NrA4it 20.
Stefan Smith rR M TO D ir"ON
wtilcoamdorit-am R. R. f
3576A
NC lVcll CorltmcrmtConifxxifon Nnitbea # •a tl :n ells;Qltllttib7c
FROM. im DiAIIUM THRIMFM MATUTAL
SAFsDACCO Inc 0 R. 2 fG 2 le 40 PVC
GornpmyNattic # c "VER NG' R"J7l8tNG3' l�iiii anti
FROM TO DMIiP,'r6it T"K,"TM MAMUL
2.Well Constmttlnn hcrrnit
Liu do 4wnrxrfrtr ww permit(Fr.Cowux,Srmr,trarinwe,frJac6ert a ir.)
O' l n, �.
3.Wrli.ilsc(check,vdlasC}:
Water Supply W'd1: FROM TO E DIADfr:MR I SIM TAT I AMAIT RIAt;
ClABricultuml t3Mtmicipatllft1lic 2 ft. 17 n. 2 IN. 020 40 PVC
Moottimml(HentingACooling Supply) DResidential Water Supply{singie) ft. ft. in
01J'KhUrial10DnTnierciai DRosidclltialWaterSu '(sbared) B:Uttatl�>
FROM I TO ATATMCQ k hSPCAC421f►AT M-UMOO&AM0l7tUi
Q1rri' Tian 0 R. 1 n: Portland Pour
Non-Water Supply Well;
n n,
dMamtotin Moco%
iajertlon Well:
17AgaiferltectOrp DGtoundmterltcruediation A 9: D t
IrR 1AT to& I -
QAgaiferStornge and Rt: m", Malinity Aamcr 1 A. 17 ft.. Sand 2
0Aguifer Test 05tommater 171liiftgc
;- :QF�r mcnim T'cchwk)M" Mubsidc=Conhoi I
20:�1tIt:41rA{i=T,A(1, . ieM�dlit�I+�t�liats sccex�ilrr, '" r. .
❑Grotimmml(Closed Loop,) oTtaoer ;FROM TO Or19t AtiPTlor abr,Irerdn.. ,ntt�xa eMe
❑Geothermal ea i o Reim) QOther' in under#21 ReinatSs 0 R. 15 R, Silt
15 ft. 17 R. PWR
4.Date.Well(g)Completed: 3-17-2 021 Well ID#MW15
n. n:
SiL Well I.ncation: (L (t. �
Charlotte grater R. n: ;..4-1
Fk-dK ADw%=Namc Fec-7'Ity WO tirapplimft)
n; rt. UAV 2021
12701 Lancaster. Hwy Pineville, NC 28134 Mecklenbur, R, n,
Pineville, NC, 28134 2td 7
t",nautj^' T9ttitiH id;rrdPirytioa Np,{tom
Sh,l.ptitnde antt Ieini4'1lotlt in ftmeslmtmmOcconds or decimal degrees 2L Certification:
(it%vff tieK ow Wang is msfHtietA)
35.066385 N. 80.872971 W _ 4/4/2021
5 of Weil Connaelnr D21C
6.U(pre)the weli(g,): 12mnantat or Mempomry IN � f retry rrrrtfy rhar the nell(o"03 fwrrr)tarunrererf rrr aocnn#mee 51grod» thdr or+n I he
41th 15A N CAC 02C A109 or 1 SA NCAC(PC:t NO µill CatwY mmt Stmldmrls and daerra
7.Is-d6 A rep»it to an tAstingwdl: Mex or Mo rrryrafrhir mmrcl hast>frn pialldnd rn1M srrlloumev.
ljrilrts tr
reywir m repsrPr,jIP1 ar+P t+rCrae wr1/cvrrusrarc°aPmo tnjorhleriart axd rxlelattt r11r rlaPwre�'ihr '
srrtdrr'021-rsrmardxA rrdn or m dae bar!of thix j6m 23.Site diagram or additional well details:
You nM use the,ba&of this page to pmAde additional well site details or%sell
8.Nunrbearof%veils oonstmeted: c onstiuetion detain. You may also attach addltiorW pages if t>sccss y.
Far*40ple Jeje rlwl or,ami-mver sW, w1h 0.4%V ntrh dm wm e Wn—slAwfim,woean
rabneitalae form rSUBAiETAL INS'CtI CTIM'
9.Total vvdt depth betaw land surfam 17 {tt;) 2da. For Ail Wells: `Stilin it this brfn within 30 dimes of completion of Well
farmtiPalplr i+eUs lisr rt!l drpdar ifd i rena(errir{rrte �dfMi'crrxl 2 :7 ) con5traction to the:folitmitg;,
I
10.Static waterle%et below top of caslng: (ft.) Di blon of Wattr Resaiir'tes.Information Pmmcessing Unit,
sy%witr bawl is above coaPng,,use "+" 1617 Mint Servioc Center,Rmleigh,NC 276994617
L
It.Borehole diamchsr 6 (in,) 24b.Fir to unmet NO ONLY: lit►addition to sending the form to the addn w in
2432bom also submit a 06M of this tbrnl.c+ithin 10 diq's of completion of%Ntll
It Wdi colstrSrstlon method. Sonic commmetion to d etbilowing: k
(i.e.sup%.rotary.cible-dind past els.) I
DhIslon of Water Resources,Vridergmund Iiejtxilae Control Program,
FOR WATER SGPPLY 1iU LS ONLY: 1636 M.99 Service Cotter,RaleiO,NC 2769r1-1636
t3a Yield(gpm) h?cttiod of test: 24c.For Witter Sol! Rrinj'ca"'Well,
Also submit one oopy of Oils farm %vitiin_30 ftsofcorWetionof
13b.Dhlnfnvdon type Amount: ukcil comstructfon to the comet hcMth depa tnim of the eo m4,whm
eonstrocted.
i
Fenn G%V-1 Nonh Camlim Dq m Uneni of Emimumm aW MhnatRos wet-t rklonotAlsim 1166ircis Rc%iwd APCuSt2613

i
WELL CONSTRUC nON RECORD Fw htanml the ONLY: E
'ttivs:farm con be used Coi siilgk ar nn llipk�+xlis
1.Wudl ContrActorinforhistion: I
Stefan Smith rROM 1 MCIRIMIO
WdtCanhitfrltAtttt
3576A tG
d .411 G butMilileatealrDoii1R4` tics ie s
WC Wdl CortisectorCanif mimNumber FROM I To PTAA4ETttR TOMPOM" MATMAL
SAEDACCO Inc 0 h. 5 tt 2 16. 40 PVC
Comytmtyhaore d6c ` , a1ND'.ORY3(3 i
FROM TO DIAMETER I 71(tCA'ATM I MAMMAL
2.Well Consmiction Permit*. tt. tt. iL
Liu 410dwaruNe•neat!pe"wo atr.Cdunry,shw.Vnrfawo.Jq dkn W.)
3.Well Use fibeck well nse): dXACRM k r _
Raster Supply Well: FROM TO I aatAMMI Nt 1 Ss.Or try: I'"11c him � M A14
M ticctdturd OmunicipalfPublic 5 ft. 17 ft. 2 11L 010 40 PVC
CGeotbennal(fleatingtooling Supply) OResidendal Water Supply(stogie) tt ft._ ita.
abuiustriai/Coninmial CResidemial Water Y
ttppt}(shared) -FROM TO rsnv lAi: 1ruCt T METHOD A AMOUNT
Ohrl' Non 0 h. 3 (t, Portland Pour
Non-Water Supply Well: M M
Zivttmitori t�lt¢co�
Injection Well: (L M
l3Agtitfcr Recharge OGroundurater iicrowintion 79MW ".
t3A4W(crStmVc and Recokery 4 R. 17 t
f3Salinilyl9amer FR fA W. FdA M-CM F[ n
OAquifcr'less Q5tommatcr rl Onji ge th Sand 2
OF--xpcdmcnbllTechnology 0subsidCrtccCordmi
20AR11.7Atst3 ' i'#'aflrkii"i16i An �I�SRi� -`'
❑Geothenual(Closed'Lpop) Mrracer PROM Ta DRSCRt a� oer�r l.aat ant mca axe.m t
13Geotheanal'(Rea6t -oa' Re=) 1301hct' under#21Remaths) 0 n. is (I. Silt
is h. 17 M PWit
4.Date WcrC,)Completed: 3-17-2021 Wjd1maMrtl4 � f4 va �.
So.Well Location: (r. h.
Charlotte Water ta. fi. M1 AO
FacilityOwnerNamc FacimytDM(ir_*ptiatb[c) Ccaa,Sli`l 11
A. ft. r,��Yivil i7CQ....0
12701 Lancaster Hwy. Pineville, NC 28134 Mecklenbur, h.
Pineville, NC, 28134 PksicdA.ddtCmaty.W4zif 21, 1l1A7taGf iy -.
1 foot bent onsite seal from 3 to 4 feet
Camel, Pared Iftfolfigtt "No(M)
Sh.Latitude andLongitude indcgnm./mimtt& cvmdsordecmaldegrecs: 22.Certirmatinn:
(401011 QK Quit tat+iong is sidl)eiem)
35.066385 N 80.872971 W1 y 4/4/2021
S of Weli Contuarlor Dale
6.1s(st+c)drehell(9}: XPer'mantra or 13TcrnpoMfY NY aigo,?X Ar fivrm,t hereby ernVj Thor rlar ntrlltlrl steps(n,iatx)tniistni"ed in Aftwrdmare
avrrh ls�'Arctc o�c.���a dr 1,3A 1�CAC nac;o2oi N�rn carslmerPan srRRderrda treuislaort a
7.U thhs a trpalr to on existing well: oVes or 0No rntm�rlu`x�rrarrt�r aproaltid�rtirnrttna�,
!f da;a lr a repot►fill onarkaraitta ww31 cr><airna+teRa lrt/ran+aelkm mad r;;'pPrtht the aaorwrr rd drc
mpaur ander#21 mfflrrrb trauae arm rhr bark nfthtr jarrn 23.Site dlagram or additional well details:
You,may use the back,of this pop 0 provide additional well site details or aV
S.Nomlat rof veils contracted: cooMiction details.You may also t!fule i additional pages ifowessary.
For mufdp i hd rioat or Rnn.W*er JW,1 tr wrfls ONLY n4rh the none tnnsgwttlaa,v o MR
Si1RAi WAL INSTUCITIONS
setea,urm�efdrra. — -
9.Total w dt depth betotr land surface: 17 {tt) S4a, Pnr All Wells:-Submit this!'onu within 30 darns Lof Completion of TU
Fear tttatbVe ivegs lrsr AM dtmas(f dya"erem teR mApfe-Je?00'MW2 @ 1M) corm n ction to the!gitou ing;
10.Static water level belovr top of cwhilp {tt,) Divislon of Water R ourtet,lnfortnation PmeeWnp lTnh,
if ntitrrr revel f shove CdSMj.uae"t" 1617!bail Service Center,Rlildo,NC 276"-1617
11.Rariftle diameter:6 (in.) 24b.Fir lnlectlon W9114 ONLY. In addition to sendingthe form to the address in
246above.also subtnit a copy of:this lbrm within 30 4%of completion of tsell
12.'%Idl vorstrirction method: Sonic Consta ction to the fbilowing:
(Le.Dttger,easy.aabtG dint ash ctc.t fthlon of Water Resources,Underprtund Injection Contra]Program.
FOR J ATER SUPPLY WELLS ONLY. 1636 MR Service Outer,Raleigh.NC 2'76"4636
13a Yitdd{$ttm) Method oftesk �-F'or Water Sa�tplr,^&in'eca01%Wells:
Also submit one�'of this foniu♦�7tltrn 30 da}sOf conpietion of
13b.0151nfaet on type Amount: well construction to the county hcttlih 4cpaailmem of the county e•herc
Faint GW-t Noah Camlimt Dq mtmmr oCEmim mmd and NaiwW Res=m-:Dhkbn aMlatcr RIe9airm Rc%-Ised Araguti 2013

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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