GW1-2021-02711_Well Construction - GW1_20210527

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WELL CONSTRUCTION RECORD For fmrwl Use ONLY:
'this forth can be farad for side or:mWl iple wds
1.Well Gontractor.infotonation:
a.WA�'tiR= a=
Zach Thompson rR M ID tvflty2t
W401 COOMC NAitle R' j
4478A
NC Well CommctorCanitfcati nXwnbrr .:t)it73 t,G ti BrNiaNi+itsed'.` Oitltal+ii',R. 8ci to i,.
FROM 170 DIAMETER- THiM*NFM MAnRTAt.
SASDACCO Inc 0 fL 7 ft. 6" tn, SCH-40 PVC
Comtparq hGtsrtc JVROM 'To
mold,DUNIF•Fat 7tHCRAr3S ,MAIERIAL
70002677 IhL
Liq eft apptirabtr aril Nrrnr is fie.CountK Soh,Varfarcx.,IrlfE 6Cn etc.)3.WdlUsc(ct�k weil u c):
Water Supply Well: Ptaa� a st o rs tttt. .MArRRtAI.-
7O DIANIKUR
OAglimItural DMDnicipalMublit 7 R. 27 A. 6 1�' 0.020 s PVC
❑Geothet ml(Hemtingtooling Supply) DResidential Water Supply(single) B' � in
OlndustrialfConttttetr:ial ORcsiftnt-sl Water S I1)'�QIIOtTT
ttPP$'(sitotnd) FROM TO A1ATrtR @lttrtAC1TMP�"t1kWM1 OD Mot
Oftriggtion 0 It. 3 fL Portland CamEntection
NOR-WaterS"PplSlVetl: tL tt:
O1vtOrritatin �Rcem
I"Jer"an e":
OAgaifetRccbargb DGtoundmtcr Remediatias►
rR M tAVr14I t Itt7NIH ;NY�t nit
DAtlniterStwageanditccowq OSalinit}13amicir 5 ft. 27 fL Filtered Sand #3
D.Aquifcr Test DStarmn ter pltt ns
ft. ft.
❑EVetimentaf TlochnologyOsttbsitirnce Control
e nxna�t�6 itlir A?siAiltaoeW"liriits 1 +ice
i7Geothemud(Closed Loop) OTeaeer :FROM 10 OEsCx1 moo*:Wn:newneD ea�hvea eva
OGbofliemlal(Heb li 'Return) DOther( min under 921 Ream& 0 ft. 27, ft. Tan/Brown Silt
fL fL
4.Date Well(s)Complded: 5/5/2021 WdIj 1#RW-2
h. IL
516 We"Location: fL ft, a>.
Wilson Air Center ft. (L
FecilhyJ0n, rName Fec04IDk(ifW{1lotte)
5414 Airport Rd., Charlotte, NC, 28208 ft. p; Utll
F,kt al Ad tess.Ci*r,artdZip q 11 .,
Mecklenburg Bentonite seal from 3'-5'
huts^ i'Atrd ldtmiPicpliQnNo.�(N)
5h.lattittudc and i ongitude in degnr.0nirmteslscconds or"mat Ott"XF.. 22,Ctiliftration:
(tf we11 JkK Oita t,,100 4s is f1dfie6t)
35.208383 N -80.929281 W 5/8/2021
51go3w of Ccit1jkd WCU Conttactaf Dakc
6.is(are)the weli(s): . Permment or oTemporxry
Ht 40Fn8 ibis fornR t heiehp LYrtrfy thd!thy-rirtttq?kAU f weYie)t+urtftr •tert to orcarda+are
wfrlt 1SA NCAC 03C,0100 or,1541VGAC(ZC:RI11A1Fe UC(Astn radon Stamdords mid 0wo
7.Is this a repair to.on e:tiAting well: 01es or ENO rnt r e+/rhk nvord hog;bem provUrd to Or nv414mwer,
ifAj,slaceo7xdr.fill mrknni"wrItrara malomh!fsmwtW mid rrplaltOw.+wrure4rhr
reMirw drr021 rmarb sweii m or rm tiu hurt m/thb/oroL 21 She diagram or additional well dt:•txfW.
You tray.use that badk of this page.to ptor^i4t additional xivit site details or vMI
S.Number of wells aonstrutted: 1 eovstruedondetaib. You inn also ouaeb additional paw f necessavy.
For nNdi*lojenkm or era-miter A r)y kWh ONLY midi rim anne cansdsrc*n,jwm ran
mdmfr WW farm. SUBMIITA)L TI�T�`�j(MOM- .
9.Total well depth below I"d surface 27 (n,) ZAa par Aft Wells: SA&ndt Ibis loan Avithio 34 dints of abrnpletion oftrrlt
FormaP,ok.wUs-fisr all4*p#as ttdgerem lest[nPapk 303W oW?07a7dY) commrtction to ft fiottonin :
Ili.Static water In'el below top of casino (R,) Diiision 0f Water Resourtfe.lntnrmgtion Processing Unit,
t/nurrr kW1 itdbatY(V ikf are"+" 1617 Mull Ser iecCcotrr.RA1dgb.NC 276"-1617
It.Borehole diameter 12" (in) 24b.For Inkrtlnn 3M ONLY:?n addition to sending the form to tbe-address in
r#a above also submit a.Dopy of;this form within 30 days of completion of well
12.'Wdi tOosttlttAlon,Method:Bored rowtuction to the follovving; 1
tie:mW ta6ty,cable dbvd#tvsh ctc.)
Dhisionof ControlPros
FOR WATER SUPPLY'%SLLS ONLY: 1636 Maf1 Sen ice Ceni~er.Rnleigtt.NC 274"i,1636
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13x.Yield(gpm) Method oftesk 2Ae For WxterSappl &tnjoctlnaWells: ,
Also submit one copy of this forin within'30 ft,s of completion of
13b.Dislnfeet ou olie Anwunt: welt consitudion to the cmmn•he'Atth dep onve tt of the county n•hert
coristmcttGvl. �
Form w-t Nmh 0=11ns Dgwtnrm1 of EmIto mmd aid dues]Resomocs-:Division ofWater Resri rm Revised ALCUst 2011

WELL.CONSTRUMON RECORD Porrt:cntalvu()Nllf: I f
'M s farm can be used for single or mulliple mess
1.Weil CAmmi torInformatlon:
f4:ll�A R b777
Zach Thompson FROM vv4M1P11QX
A141 Co aracW Name R. It.
R.
4478A
NC Well CoanuctarCenificatlonNufter OOT1?R (3 rimiMiofwtil tlft peal k s
FROM, To DiAMF,TFR TRICKNM MAWRrA1.
SABDACCO Iac 0 fa. 7 fL 2^ ie. SCH-40 PVC
Coa",Name
","aC�QitBlNGii kfYtl�":ftiseAa... -
FROM To DIAMETER TMCKNUS MAIVUAL
2.Wc11 ConstiVerl m permit*: 70002677 ft. ft. ;�►
Usl&11 aM(ir uble rcrff penrits fix C.vuwn ,Setae,Varia r,ftirftt r1r.1
h. #a. 1n
3.1Weil Usc(shah cilarse):
Water-supply Well: FROM I TO DIAMEMR WT SVZ I TtitC7KXM I MATfOt.t L
OAglicultinal CJMtmicipaltfitblic 1 W 27 ft 2^ 11L 0.010 SC I-40 I PVC
DGeotb rntai(Heating Cooling Supply) DResiderdai Water Supply-(singla)
01ndustrialfComomdal DResidential Water'Suapply(sllamd) :17Rv
FROM 170 MATRML EA1TLttTJ 1NTMEMODA+AJOQ .
01nigation. 0 ft. 3 ft: Portland Catiantection
Non-Water Supply Well: rt
mhlonitorin ORecoi
Injection Well:
ORquifcfttectiiarge QCitoui►dnttierRautu+ditttimi . .
-.
p St c and Recati i sal nin,Harrier Fa A .a 1. ItMaa�i
' 5 fL 27 ft. Filtered Sand #2
t3A gv*rTcsf 0stomm"cr Drainage ft ft,
❑i qaa rtmrntaf Iechnolagv Mubsidc-m Control 30UR11A,ihalf}f!.atitfEhdd1(forr ttihetMs3flithessara
oGeod mml(Closed loop) O')lpcer _MO'M TO aFSCRIPTtOR or�r.G�Nn anaVrnek mac+
OGeotbemral(Reed neRemm) 13Qtlter lain under#21Rematbs) 0 h. 27, ft. Tan/Brown Silt
ft fL
a.DateWialiOContpletedi 5/3/2021 Weil M#MW-17
fa, fL
So.We"lamatkm: R. fL
Wilson Air Center ft. ft. P�'c "
Faciliw,'Qu ner Name Fastlily wo(if appl Mbw) (L ft
5414 Airport Rd., Charlotte, NC, 28208 ft, f4 y
PlpsicaiAddmmCiq.and tip L 2ty hfA (li
Mecklenburg Bentonite Seal from 3'-5'
j.0n
Coaiatr' Pared Wfairaelitlan No.(PIN)
Sfa.l atitoda anti ti6ng1todc in degree,tJmimat 0tscrnnds or decimal fa 9MM' 22.Certifwotlon:
(Ituell t'K sale latgofts!s flotticm)
35.208288 N -80.929323 W 5/8/2021
siganbue of Ccit1ftd wa Ccnuactor i Baas
6.1a(are)the aseli(s): StPernment or OTemporay yrgnins n rtorair f hr:rh�•.e:rr tai;s rl «rlgs7�,sr{wr l asr uer�d/,r,►cre ancr
%•tits 15A NCAC 02C.(t100 or 13A AFCAC(CC'A200 Roll Coastnar doff Stm lards and Oki a
7.InthtsbrtepArtoonalstingwell: oVex or MlVtt twrrFnjrhirr++wurdh�cbrna�rar&hYlrri h_,.r�ltowvrrr.
ryalkfi'ara rrpatd fiJ!artr:bav'ti�u�ad!ae+asnucviam tnlrtranark+n.nutr�+taJir rke raarara of r/rc
rrryrirsarelrr33t re,avaNts'aw c#razry ar rara tfre bract rijrlds forest 23.Site dingrom or addidowlt iveh dettiN:
'Yost unary use the baeb of Ns pap:tt pmiale adtlidonul'uvfl site details or well
S.Number of ovens c onstrneted: 1 construction details. You may also a facb addititstml pages if amemmy.
For*&flute 1%crlon,or am--a wrr iW4?N wrtla 0AIM'rill Ar armre eonsfmuelloo.:�ww M
rrhmrir fof+a SUBMI CEAL II11S7 LIC170IVC
9.Total smelt depth be(orr land surfam 27 (iT.) 24a, lrnr All Wells: Submit this form nithin 30 dot•S.of a intpWon of tir)1
AvAwlopJe wefts list all dolr*s(diffkranr trraacatrGr-3�d(Mt'awl?�7+�d1} wnStnwkn to the lollmving i
.10.Static-is ater Intl belaw top of casing {ft.) Dif islon of Wow Rtsoura�,lofnnnstfon.t'rotessing troll*
tf v ntrr kvtt it shrine eaalsg:.tier"+ 1617 Mail Service Obvier.RAleigb,WC 276"4617
11.Borehole diameters 8.25^ (in) 24b.For Infection Welts ONLY.i in addition to sending Ric fort to the address in
24a a mv— also subunit a Dopy of Aws fors within"days of completion of ii�ll
12.14reil oonsirnction McMod:Bored wnstruction to flk fallowhi g:
fie.a r,<fmiy,cable dims p"stt ctc.) Division of Water RexOnAY1lIa
t<Qildergroand Tojection Control Program,
FOR WATER SUPPLYWELLS ONLY: 1636MailSen eeCenter Ralelo,NC176997636
131L Yield(gpm) Memod of test tic.For Water Sant&&tnj_o Lion Wells•
Also submit one copy of:ft fofin',irithin330 daysofoorupletionof
131).Disinfection type Amount: tii cif coastnaction to the sourly tic°31[h dcpartmern of the comfy w b ac
constnictcd.
Fan"GlV»t NoAh camiim Depanwerder Emivon=W aad Nararal Resotaws—Dhision ofWafin imurtstit�IsedAi 21)l3
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