GW1-2021-04161_Well Construction - GW1_20210827

WILL CONSTRUCTION RECORDFor 1 mvndUsefJNl l`:
`IM form am be omed for Ar8k ov awfi*Udis
1.Wdl G utractor Information:
a.W
Stefan Smith �? ��' FROM o iPtiO\
%Idl or iorltac+tt ,➢�,�'' ft. ft
t
NC;Wd)CofinectorCmificailonNembcr
FROM TO PLA:%tMR M MA7ERML
0 tL 4 A, 2° la. SCE-40 PVC
SAEDACCO Inc
Cma aaag ttaarrte \�t3t�.•1�,�,i tBu1' 3+T xlR tFT i e**1
FROM To nt&MFTER I THK*kNTM I IMA74'ML
Z.Wdlgnttt7ucAianrinit it 70002914 fr ft. 1 is
rlu ufi asppticuhtr tsril prrmlPx fir.County, ,Vorinnrr,Itpa[Ca�rtr.) tf. A4 1tt
3,Wdl Vse(dte4lt Well use):
Water Sn111f1a Weil: FROM, tO. __ DrANKMR MOT Ttl1 MAIMIA14_
Clf grivltuml amunicipaltmoc 4 R. 19 ft. 2" ins .016 SCH-40 PVC
Mkoftnnal>(Heaf7ngCDoling Supply) 131i sidential Water Supply(single) . in j
dlndusitiaMonimadal DResidedtull Water Sapph ftte l) A tiRoi11
taROM 7t! ?V1A1=1AL MRACTiMF«�tT On aQ AMOt:lQ7
t7l"• lien if. n.
Non-Water Supply Well:
i&i4ftanitori I�Recoa _
u1jection well: ti. (L
C7Agtliferltecftltge OG1oundwateritemediaticm :5 U t .tf"
rtR MTo mAm- 1AL ViA
0Aifu!(cr,Stonc and R=vcq 13salinty13amer 2 R. 19 fr: SAND 20/30
DAgvifer Test QStoma�catcr t3rnirw9ge
fL tt.
OF-Wrimcntal Tmlmolo C]S1�sidencc Cao-ldrol
3+6:ARItL11t#i1.C) �i1�1+ae�Tiixriix'l�ficr+tilf,
z
DGeodvetmttl(Closed loop) Mom FROM TO PFsG1aFu7o?; rAt+t�.einrm 4nrUnsrh aasm eka
BGeothernal ff nui ooli " Reim) DE)tltet(' lain under621 Renuft)j 0 tt, 8 (L Clayey; silt
8 ft. 19 (L Sandy silt
4.Date Well(s)Completed: 8-4-21 We11lp#TM-3
Sa.We"liacatlnn
The Ardent Companies tL tr:
F8C11k-0%'mrilame Fmil1i?IDNcirupFliublef A. ft
6500 S. Blvd, Charlotte , NC, 28217
P1"—WdAihlxss.GiEY-N4Z1p
Mecklenburg 17304204 Temp well. Saaded and sealed w/ hydrated
o naw Patoeiidemif utionN®.(PN) bentonite
Sb.l otitadc and Longitude in dcgr oWmin atcAcuinds or decimal dew 32.Glertif'ccstion:
(if+nC11 fiewt mu b4tlors is slentiad)
35.144738 Iv 80.876971 W 8/13/2021
Si�rsi of .. mdWefiCammctos Date
6.is(orr)iheweli(&): 4=tP fnalrent or StTemporaryHy;gg1jing#a/eWK r herrbv ivifify tho Ar n rllfs)*ft t,e J evo n wed in ftVbrdemt e
��x�tit rvcnc nz�c.ofrx►or tea Ncxc me� ll�u c�,ri�,:�wt st��rd�r.�a+td star a
7.Is this a repair to an odsting well: t7YO or MNi► rt r N�fr tmtr+t#hma hn'u pmtQrlyd t�etir wr>'1 atc�Fr.
tf db4 h o apaht f l mr kwftw well csastrlak a tansy tion and r_Wfaht rho tmn+re of dw
nWirwrdrr#21 re orb sermon or m t!m hoer of fhU form: -23.Site d1agnm Sir additfont tech,details:
You ttW we the lack of this page to 0mide additional Well site details or well
$.Nttnlberof ells eoustrnCtcd: 1 construction details. You may also sdfach additional pages ifnecessary.
For mrattAWrittferrk+at or am-%raver sjT#,t wylls ONLY u0A the arms tmstrrrcttan,yam can
ULbmfrmmfmA Si7BRt A dAS
9.Total well depth below land surface: 19 _(ft) Us. Par All Welts: Su bruit this f'ann within 30 dn1's of tx►unpirtlon of"VU
Fort obi0k wash i all depth(fd0mx7(xampk-3@200*and 2@11W) constn1ttion to fttothming:
to.Static grater leve below top of Casing 9.5 00 Di�ttiAri of WsterRcsnuiu�ee,tnfotmatlonPm�ssin�TSoit,
IJawrrr Ott ri it aftrrar ewrArir<�sr"t" 1617 Mail Scrtiec Cc uler,Raleigh,NC 276"-1617
It.BturehoM dirmeter 6 (in.) 24b.LU lnkolto Wc11s ONLY- En addition to sending the foml to the addaess,in
24aab6m also sabnAt a copy of this form:'within 30 days of completion of idyll.
1.2 Well cnrisirnction method:AIR conshuction to the:tbl owing:
(i c.r4.r mfw.colt dmd oasis,ctc:)
DhUlon of Water-Remources.Itndergrunnd Injection Control Program.
FOR WATER SUPPLY'%TLI.S ONLY 1636 Mgil Sem ice Crnter.Rniclgh.NG 276491636'
13a.field(mm) Method of to 24c.Pnr Water Snpp!y.&INecdonfWelic:
Also Submit one cow of this form iiitbift 30 days of rafapletion of
w,'
13b.Dlxln[u:ctlan tip Amount• cll CoMhuCtion to th County t e Coty hca"depainne of the county when;
t:attettucted. I
Fann OW-1 North Czmfi a lit of EenimmwA stet Natural Remwms-D'n+lon of Water Remirms Itmiised 02013