GW1-2021-06372_Well Construction - GW1_20210915

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WELL CONSTRUCTION RECORD
For rntcnml Use ONLY:
M.s Aeri t c;rn be usod W singid'mr rm-dlipk wells
1.Well Contrtctorluformatlon:
„la. VrATERNES �:.
Brian Ewing FROM Tut OKKKflPttox
�'C!I Crr( gt�r Ntirr ft ft. L - -- -
4240-B ft. fL
NC Well Camm arCcnifacntibnNwnbra 15..OUTER CASING 0brxwhJtsiatii+nxl9 ORIJNERMA`mahk
FROA! I TO PTAmw;TER TErCKxF,%5 I b1XIEAiAi.
SAEDACCO Inc (L
CarntpmyNorm 16'1N,yER" Nir.mt,'liUR199 iberuai tki"416661
FROM TO DtA51FTER., THICKNESS ALV1ERfAL
2,Wt:11 Cpn.5tructian PciTnit** 70002060 0 ft. 21 ft. 2" 'in- SCH-40 PVC
/iu tr1d�r,�tierrble tccjlliemei0r tFX'�Gnxarro,StnN!;lanriamer.Itl'soar;evr-.j
23 f4 25 f4 21, hL SCH-40 PVC
3.F el],UrS (t;hcelc.nell a50"
Water Su t tl'
l 1 !Well, FaaOAt TO orANtt:1'0 I srarr'stIZ I TtarClc'AnS I AlAretarpt.
f�11$ficult(iral C314fMibNpa1A)ublic 21 ft 23 ft. 21, in 001 SCH-40 PVC
CIGeothe,mial(Heatin oolinS Supply)ly) DResidential Water Su ft. ft°. in
pPli'{sin1,le1
0ladustidaKornnaercital Oftesidential Water Supply(shared) `I&GROU1
FROM TO MATERIAL EMPIACEMLNT AW11101)&AMOUNT
016i Lion 0 It. 17 fL PORTLAND POURED
Non-MIAter Supply WOO:
❑lvlorailtorin l7Rcco�r ft, r4
injection Well: rt f4
CIA4uWcrRccbjrgt OdmuaidvvatcrRcowdiation 79:SANd}t:itA«I i'1t - 6WaIVIt t►k},
FROil TO I NIAT11 JAL, RAtat.Ar:t rt",T,t' :•rut n
MAiiitdfcr•-S`torrge tr1cl ItcG v l7fialinity Harrier 17 ft. 19 ft FILTER SAND # 2
❑Aqt ifcrTcsi O'Stomrn at0lira ar,7ge
ft. rt.
❑ETri mental Technology OSattrsidcrrcc C Wrol
10:nRil,1.J�G1OCs"(aiiacb�dditiilna"Is"hf•eis�ifsocccafsr�. '
❑Gootheuna!(Closed Loop) 07raCet Faatar Til pEseRrH'T!O\anbr;ArirdnCw+ ,a'n,curr i arort
❑Cooth natal(Rea if t:00ii E Relntan) ®t}t1Yer(: airt under#21 Retnatl sl 0 ft. 15 IL FILL SILTY SAND
15 ft, 25 fL SAPROLITE
d.DAte`4'ett(s)Coptpleted 8-16-21 Wcl jD#ASW-55 e�
Ax,Wdl Ltteation.
United Parcel Service 14 ft. C 20
FaclifyaGwncrNNmc p'acl tl-1D#�j1 sappliesbjc) J
04 fr,
1600 Cottonwood St. Charlotte, NC 28206 Mecklenbur, ft
r;i;a�l:a• Ca^'140D
Charlotte, NC, 28206 P1O�secai iP L Giq'.,and Zip 21.`ItF I►tAlti:S
Mecklenburg 07714104 BENTONITE SEAL 17 TO 1'9'
coutkv Patta ldrfOrrc;UiolI Nd.(PIN)
Sb.Iat4itudc and Lo'n0itudcin deg cirhninutca!lscconds or iccinwl 4cip'"s. 2l Certification.
(ifiti,cli'fGlgcn tanllpt iR friltleiCtrtl
N W` .Briar Ew ng 8/20/2021
Signamr'aft'Tttitea Weil Conte"tar Date
6.Is(are)the:*cell(Sj: zPer taneut or oTemporary
H3`er'gamg skis fivm,l trcrebr•aerhfy thuv,the,rw*(x)uatr(n-e+a')amttr,reted do(mmrti+ritnncr
sorb'15A NCAC 03C.0100 or:1JA,ke,4C O2C.-0201t 14rell Goimt ;t-rft4et Srmadar fs wo thtrr a
7.Is this ar relrair fit an existing well: ElYes' or K No a`arpy rlus record Jana darn[✓T4A-W rn ow,,%ra mwrer,
1 abts'It 4 wpair.fill awr trail )(�!re rasmtcvfmv ht1"armfion mans c-apfaira the rurrore c+f the
repai"ModerP21 maardr art7ro,e bray the bat of lhix fnrmt. 23.Site dingrtim or additiotial well demits.
You may 6se.&back'of this paip to Otdide additional my l site details or bell
8.Number of ttiem constructed: 1 c-onstmetiott details. You Indv also attach ridditional pages if uecessaA%
Fnr ma ffipfr hrjeeikm tw nm-+,surer imp*a elts ONLY ndrh tic mme carnsarare"r,y"con
=bmit ave forma. SUBAtTI"PI AL 1NSTiWT70NS
9.Total well depth below land surface: 25 ((1(;) 24a. Fbr All Welk. Subutil this fordi titltin 30 days of comp1cti6rt of welt
For e,tttj4ple iveffs 11sy 47114femks Td'f,crew(e,ram Pk,-J@2W a?,n'2@ loft'} consumption to the foll€tesing:.
10.Static water level below top of casing: (ft.) Oirisiou of Water Resource,tnfirrntation Processing[mitt
If s„<uwt kM b above.rrrstng;tare"t" 1617'Mait Sen•ice Center,Raleigh,NC 27699-1617
11.Borehole diametcr:8.25" (in l 34h.For tnicrtiori We71v ONLY. In addition to sending the foma to clue address in
24a above. also subtuit a copy of this form within *0 days of completion of uaell
12,Well atofrstruction RmAbod,'AUGERS constniction to the folio4iuke:
(i.e.mgcr..rvtary.Cable.dirm push.etc.) ;•
Dh,ision of Water Resour es.Uader(round Injection Control Vro&Ant,
FOR WATER SUPPLY WELLS ONLY: 1636 MA,Service tenter,Raleigh,Nb C 276"-1636
13a.Vidid(gpm) Method of test*. 24c.For Water Supply&Imes m Wc%
Also statimR oni copy of this Mini within,30 65,s of completion of
13h.Disinfeahin t rpe: Amount: well consinratiou to the county 6,11th ale'paarncut of the canrnty tvl>
constructed.
Form GW-t Nash Carolim Dcpwtuant.of Emir mmit and Mi,-ineal Resources- whbo of%Iwerftsou t5 RcOsed At gust 2011