GW1-2021-05387_Well Construction - GW1_20211013

i
WELL CONSTR1TMON RECORD P" For incrnattl:e ONLY:
Ths fora am be aged for single or ntW1f*arils � .
1.Welt Cumtracforinfor matlon:
T 1 2021 AkWAM,zv
Stefan Smith i1��� 1 J Plt AlTo 01MCKIMON,
W41coaftnctorNarne ^`(7CGve�g.M1 fL ft.
f�CC;',3f C'%On M ft.
3576A �C�, p��R sa
Nc-wdlCordrxlotfeatificalinuNnnber i.iltl7Rli' Qiteriad IJAV d eA Olr"(w.3t y fable
FRaM TD DiAAJE7�iR TttTCh'taF,tCS I MATF;RrAi.
SASDACCO Inc 0 rL 9 ft. 1° 3e: SCE-40 PVC
Coa>itrorl'le !6 iNNP.ti NG OR if Gr air
FROM T DViA1FWR- TniCK 7M MAITMAL
2.W c1l Con#mcdgn Pcrmlt#: 50000079 tt. A&
fin all explirdRe,wrapenNits(Er.Cmmty.Ste,Vhrionre,IgTTedCn cir.1
3.Wd1.Ilsc(check wdl sae}: #
Water Supply Weil- FaOM _To I DtAhJKTRR Saors6 n 1W MATR 1 4,
CDApticulhlrai ammicipaTirllbiic 9 R. 19 ft in 11L .016 SCE-40 PVC
OGeotbetmal(NeatingCooling Supply) OR.esidential Water.Suppty(single)
Olndusaiullt ommercial OResidentW Water Supply{shred) trftoelT:: . '
FRAM TO MATMIA MAt:"ENT MEMOD&ANOUNT
Oltri tion ft. (L
Non-Water Supply Well:
i&tc�lonitorif l^1Rccoti A.
InjectionWeil: IL IL
t]tlqttr(crRccfiarge; QGruntndnatcrltemedil»ion t9. �..,
gr�►goifcTstornSc and Rtxa�rty OS tlinity Aaiincr urft M 'I Tntetat Fanrt A ' Jr;�T:N 1 »
7 fL 19 ff. SAND #2
OAquifer Test f3Stomm*cr Drainage
OExPgcstal`X'srtmokrgs Osabsida=Control R ft.
so. Rna.�v r ov:r,�l>"�� etttoR�i
Meothemvd(Closet Loop) OTracer 0074 TO DrsCarFrtoN'Dear u+.rdn a,wwrca e/e.
17Gcodietalal tit y Return) o0flw IMIaLn under#21 REm&I 0 ft. 17 ft. Silt
17 rL 20 ff. Sandy silt
4.Date Wcll(s)Completed: 8/31/21 WdllD#B-6
IL fL
Sit,Well Location:
Shell Oil Products, US rt. (L
Fx@ityt<hN'wr Name Fraoi>it?TDA Cif 9PPlicAl0
101 W. Woodlawn Rd., Charlotte, NC, 28217 R,
P)p-ical.Addresa Olt.and Zip 21 N' s• r! y.
Mecklenburg 16903203 Temp well for groundwater grab sample.
Couo> lrirrtet WsdilkrttolMo.MN)
Sb.Latitude and taingitode in degmeshninutcAcconds or decimal degrees: 21.Certirtextion-
(if aeit flow aK wort 1S sldncicol)
35.178814 N 80.883939 W 9/28/2021
5i�i of zfld Well Cartlmcror Dare
6.1s(err)the weli(s): ElPerrnaneat or OTemporaty" ur s; A this 1 ht gal g form rc6)•ewr6A thdf rhr w+r!((s)tarf ft*&)wnffrurred br ot"rdrwnr
afth,15A ArCAC 02C.01M ar 154 NCAC O.C'4200'We(1CoitstroMon SrArAmfx and cheer a
7.1s this a repair toantrtist3ngwell- Mat or ONo ae�yaJrhlr+rrnmhesliren�r+rfdrdmtlarurllaavrrr.
If Ws if a r+pOn fi0 out bwA m well eonsmtc lion btfamawrlvo and tuptabt*e+enure?)f A.
selvir rcreder621 nmrarlis weir m ar an ttm bark of th(s farm. 23.Site diagram or additiottat well details:
You nap use the.back of this page to proride additional hell site details or well
B.Number of veils constructed: 1 construction details. You mmy also attach additional pages ifnecessan_
Fo r nwNple lqjergm oe mm-uimr slum wells ONLY"Ith the erne coxmweden,vane can
submhowfirm St7BMITTAL 1N MUCFlONS
9.Totai twdl depth below land surface 19 {it,) 24s.,FAr All Wells: Siebndt this,form nithin 30 days,of coratpkdon of Jreit
Formwldptt arils lin till&r*-t lfd4ffewnr(e.V&gple+B@2W'aM 2@l+Y) construction to the-fbuowing
10.Static water level belowtop of casing (ft.) Division of Water Rtsoirrcts,Information Ptneessing Unit,
if%werlrvel Isdbove rating.use"a" 1617 Mail Service t inter,Raleigh,PVC 27699460
11.Borehole diameter.2.25° An.) 24b.Err lukWrm FUM OM Y: In,addition to sending the form to gte address in
24a above. also sOmit a copy of this form within 30 daps of completion of rayed
12.Well corrstMetion n Vabod: DPT co rAnictionto the followiAg.
(ic eager.rotary,crlble,diem pssk eft:)
Division of Water'ResoorcmVitdergrodud Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Srri9oe Center.Raldab.NC 276"4636
138.ti end(gpm) Method of test 24e.For Water Sapp&&injectimi Wells:
Also submit one copy of this font within 30 daysofcompleaionof
13b.DiRinfectioo type: Amount: well constmction to the county health deparhnart of the county tvhm
constructed,.
Form G6V.t MAh Camlim DM mum of Ewttowne>p and NamrW Resomms-Dhislonol'A's&Resmirces Revised ALVA 2013