GW1-2021-05385_Well Construction - GW1_20211013

WELL'CONSTRUMON RECORD For lmtnd Lin ONLY:
TLis roan con be and for sftk or m drTic 1Xiis
t.V►'c1t Grntrarxor.irtirtrtnitton:
fi 31' lEI2 7.Q..
Stefan Smith s ••M VR M_ n- ► 1; v
WdtGpndr,¢durK�mC �
1 11�ti '
3576A 0� e�r;�\1��
NCWc1lCommctorCenifecallon �r Nanc �t,G"+�`�I�rrC"C'� 5 ztATtt oriiriih34drtie 'OR;` "ll[ifi16
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TO DTAAttT6n 3irnGiCItPS3 MATERTAi.
SAEDACCO Inc ft, 20 (l. 1° la. SCH-40 PVC
CamVwv Name rOA [NG+ tirertiA d tl d 1' " ;
TO01MA11761t TI11CKNFM MAIERtAL
50000079 Variawr,llbEeknesc3.Wc11.lise(d;vck well ase):Water So lily Well: orAMBt7:R T IY1: 1rCUNM MAiTMAI,
OAgriculturel DMimiripal/MliC 20 ft. 30 A. 1° to O10 SCH-40 PVC
DGeothernlai(HeatinglCooling Supply) Meriden t8l Water Supply(single) R (L &
Dbidustrial/Conutmicial OResidentkii Water Suppiy(shared) MX
FROM To WAI HMNACEM=TrtrI on&.010UR'
C&d lion tt (L
Hon-Water Supply Well:
®Monitori ❑Rcxcn R. R.
injection well: ft. IL
OAgITlferRccbcgc ClGrout drraterilcmadiation rM0111M
M A'PFt!A1 pMhrA �tt"170 n
OAgni&r.StoTageandRecovery 0sall"ity Darricr ft. 30 fl. SAND #2
OAquirfcr Test DS1011rmatcr Dmirmgclt. ft.
OlrVCrimrntal T=lmolo,� L7Srlbsideaoc Contml
OGeothernml(Closed :oop) tlTraeer 7D nrSCRO'"Or 0614r, M
OGeotitemmt Return) 130dier. in under#21 Rettmft J
0 it. 19 h. Silt
19 0. 30 & Sandy silt
4.Date WOW Completed* 9/1/21 WdI M#B-9
f. fl.
58.N'e111.rtealion n fL
Shell Oil Products, US ft. (L
FaefflilyiOn-wrNemo Faeilk MR(f sppii--able)
101 W. Woodlawn Rd. , Charlotte, NC, 28217 ff. ry,
PlosialA3tdM- iq_andZip
Mecklenburg 16903203 Temp well for groundwater grab sample.
Con/ay; parcel l4cmiRM005140,(PIN)
51t.iAtimde and Longitude in dc�atlmlm tss/seconds or decimal ciegrt�; 22 flan:
(itweit fici4,("it 1300f%is$JdYklttd)
35.178722 N 80.884078 W _ 9/28/2021
5 ..1tod'Wets Cantmscnt Date
6.is(ire)the well(s): aFermanent or oTernporary Ay signing dtlt fonrti.t hereby ivrriA-A&the µ+ell(s1*as-1 rrcrrl cantrrrrrred in&"Alimce
wlrh 1 fit hICAC 02C.0100 or 15A NCAC 02C.020f1 WrU CAmrm Won Sraa* d;and dw a
7,16 this a repair to an eidsting 1rell: Oyes or wNo rpm of fiTr nvonf h"bere pmrum to the nrM QUWr.
If*s&a repdr.flit ow RfP M well carurnrcrlea iltl'om f wr and rTtak the rmfure of Me
repair ander#21 remarks merino orris ds bare ofd*form. 23.Site Magnin or additional well detaiist
You may use the back of Ws page to pro ide additional xMi site details or well
S.Number of wells constmeted: 1 construction&flails. You mq also attach additional pages if necessary.
Fo o u e%tkm or awi-u alee tub wells ONLY nf(A die woe conAwe-flan,y.�v nine
fn .rLVBB 1"rTALMSEJCT?ON$
9.Total weltdepth bet mlandsurfale: 30 ((L) 24a. Por All Wells. Submit this.,form within 30 days of completion of still
For areuhvrW111hre all Arluks114, emiltertae>pA"-3@3(O'am20100) construction todicfollowing;
10.Statlewater level below tap of casing: (ft.) Division of Water Resoamts,information Processing Unit,
1/wW/rrWe'lisdbotveadnit cur"4" 1617 Mail SeriiocCimt1x.ItAltigli6NC27699-1617
11.1iarr8ote diameter 2.25 24b.Far[lrhxtioa Wetic ONLY, ,'fn addition to sending the form to the address in
24aabove. aiso su9tinit a copy of this faint within M daps of completion of awil
1.2.Well eonstrMllon metbod:DPT construction to f following:
(i.e.aipr.rotaty,csbtc doxr posh eki
Dlvhlon of Water Resources lU bderl"and fnjecdon Control Program,
FOR WATER SUPPLY ANTILLS'ONLY: 1636 Mail Service Cduter.Raido.NC27699-1636
13a.lileld(gpm) Maw of test: 2-4,*—Tor Water Sale&&tnicatimi Wells:
Also submit one copy of this for M within 30 daps of completion of
13b.Disinfeetipn type: Amount- -.cell constnrction to the county health department of the colintp whew
constmcted. f
FGIMGW-1 Nonh Caroling Dgmtme uaf EmimnmcN sod i AntrW Rcwurocs—DivhbnoM'xtcTRe0UM Rcvlsed August 2013