GW1-2021-07514_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD For irterml Use ONLY:
This form can be awd Bet shtgle or raaltiple caells
1.Wdl Contractor information:
John Eisenman PR MTO 0P.SC UMON
W'41 Cta*Ww Name fi.
4439A h. ft.
NCWcllConuaclorCcnitit wbnNam6rr Y O � itf QR1 tt
FROM TO WAACITM T"Irk"M MATERTAL
SAEDACCO Inc 0 ft, 10 fL 1" im. SCH-40 PVC
C7natfuin)rlaunc s.1` _ Ci1519 ., 1C:24tiam4164*41hat'etas
FROM TO I WAyit:TPR 'rtitCATRSS MAtT.R1AL
2,�Yi31 tuon.cgvc:Eort Permit#: 70002937 tf, tt: hn
lire aliepplirUNI.Uvo permits r".(aunty,Staff.Variance.110kearm eh:i
3.Well Ilse(chccic well vs*
t'i.SCiY _
Witter SupplyLTi'dl: PROM TO P1A'MRTFlt S1OT5fsr '►1f1 � MAMIA1.
C)Agricttlnitat amonicipalf tblic 10 fL 25 N 1" to .016 SCH-40 PVC
C]Geothetmal(HeatinglCooling Supply) DResidential WaterSupply(single) h'
ObdusttialrConittlefdal DResidential Weiler Supply{staled) . . . ti..,
PROM YO MATHRtAt tPGh FC�17 Mt'itiOn @ AMA1fiT
Ditri linen ft. R,
Non•WaterSupply'Well: tf, ti
smottitori t7ttccan
Injection Well:
pAgttiferRcctt3rgt QGtoutidnattxltcmcdiat9on 119.$'' lG rR r IATfMIAL< Pfp]# M).TN n
DAtltlifcr Swap And Rstrfmvy OSalinity Harficr 8 IL 25 ft. FILTER SAND #2
DAquifci.7test DS(omm-mrDrainage
fL ft
DEVctimcntat Technology OSnbsidcncc Contmi
20. lt11:13tCGLWOG r1 vdd1fl p1 tieetSifitcM"
❑Geothernml(Coxed Loop) OTracer FROM To aR5C IrnON color:A.rs eaRmct: e�etc
DGeothetmai(Hestia oti Return) DOtlter( lain tuxler 021 RemaeKs n' (L
ft. %
4.I)atoWeil($)Completed.. 10-20-21 Wc1lIB#TMtf-1
ft. ft
5a.Well11)catlon: R. f(.
South Boulevard Assemblage A. A. `
Fw ity,O=Nam Fecflity 1D@(ff appLimblc) ft. tl.
4001 South Blvd., Charlotte, NC, 28209 ft. ft.
M-skit Adlt+rss City-.and Zip 11aft':A tz :i N
Mecklenburg 1" temporary well / PROCESSING tarp
Wuah• Pamd Ideal tkation No,(PIN)
PC 16-
.5h.!altitude and t.ongitude in degfccs/mimiteslsceondsor dcelmal degmm . 22.Cettifkafmn: NOV1 OtMrtl kK mic to � �d �) 6 2021
N W �n'. 10/24/2021
Signs tirt
6.1s(are)the wd1(s): t 2mminent or ;Wi Temporary u.
n-ftll IM NC.AC 02C-�. '7..`4N :%dC.020(1 Well Const r atan SW1,4mds and ow a
7.is this a repair to an existing well: DYcS or MNf► rvgF cff this r rrJ!>as J6arn prp+��rkArn il4r nrdlrmwsr.
if AIS 1941 reprNr.J111 ae+l n wet!t»xurea tM 1'tfnrnartrian self erpkin the Adair#rJ the
repairsnderd?1 remar*x snum or an the lank of this form. 23.Site dlagram or additional well details:
You may use the barb 0f this(rage to provide additional nil site details or well
S.Nomber of wells constructed: 1 construction details. You may.also attach additional pages if necessaty.
For moMrde,lrttectk vi w Aran-%pater jW$y writs ONLY n4di dw rmxe conspwtfatt.;war can C 1B i7TA1 iNC"t[l�fYONS
"a wah rune foftn
9.Total welt depth beta ;land surface: 25 {t�,) 2Aa. For A Wells: Stubmit (his form within 30 dayt of completion of-Well
For mofrtpfexxltshua#JpAr(fdflYtrewtex.Wte»3@2Q0W,?@10(r) constmctionto the fgttoning;
10.Statue water l"T1 below top of casings 00 Division of Water Regnurtes.Information Protesting Unit,
if%,aver keel isabaty edilag,toe"+" 1617 Mail Service Center.Raleigh,NC 276991617
11.Borehole diameter:2.25" (in.) 24b.king iUWWQn Welk ONLY: in addition to sending the ford to the address in
24aabove- also subinit a copy of-this form within 30 days of completion of well
IL Well coltsttsfetion method:DPT eonstnretion to the tbtlo%vhtg:
fic auger.mtaiy.cabtc dirm posk eft.)
DlyLvlon of Witter R.esourt:ea,IInderpronml lnjedioa Control Program,
FOR WATER SUPPLY AVELLS ONLY: 1636 Mail Sc Moe Center,Ralelgb,NC 276"4636
13a.'field(gpm) MCM04 of teat: 23e..For Water Salwx d'c InJottion Welly.
Also submit one c off of this form within,30 days of completion of
13b.Disinfection tyjw. Amount: .N-eli construction to the comity hcallh depitmant of the county wlicit
constlticted.
Fain GW-t Math Camlins DgwUnrnlef Eanimnmrd and Natunil Rmwocs-Dh+.ion of`VatcrResovaes Rc+•iscd Af.6d 20t3