GW1-2021-07750_Well Construction - GW1_20211116

WELL CONSTRUCTION RECORD ForinWanmlUsc0Nl.Y:
This team con be owd fa single or mtdliple wclis
1.Well Contractor Information:
lit FAQZONES
John 81senman FROM Dr,$t'S"floY
%Yell cunimaor%'tank a, n.
4439A it. h,
NC Well CammaorCenilk,smionNawabcr i,dlT1 Felt�i#S11tG ei inufl ssclt OR 1Jtrl�i D``Hcaa
FROM TO DFA�iMR THICIMUS MATERIAL.
SAEDACCO Inc 0 ft. 10 fi. 1° in. SCH-40 PVC
com t y Nanrt 36 I 51 T R: . G Ilt+m' kr kA "
FROM TO I DtA.RliTIM I 74tiCRN M MATERIAL
2.Wrjl Con,,0jVC*n{'crniit#-. 70002937
list all ax4im6le rwwtlsrem its fir.Cmmre.Seer.Variamre,bterNat esc t h
3.Wdl,Use(chock evil ase):
Water SupplyWdt: FROM To I-nl la19YER,I 51ALT sst I TtnOlc: VA"..RTAi:
OAgdculmml l7Mtmicipallmlic 10 ft. 25 ft. 1° la .010 SCH-40 PVC
DGeothemtal(HeatinjVCooling Supply) ❑Residential Water Supply(single)
OindtlstriatlCoplincicial 011csidentiai Water Supply(stomil) ti iJROUI �_ : _ ,Z, U
veoM To � arnTentnt: gnn*t�cfr 1 Mtrtton�A11i taut
❑hri Lion h. ft.
Non-Water Supply Well:
®1•iionitoli n. r�...
ro ctlon Well: fL fL
DAguiferitcch9rge l�Geoundvm1crRctncdiotion IA.B •r, d
Fa � A7RRIA1. ttMpl raCl'.NT,TN n
0A{JWcrStQn cijn[11 C60*ViCj ❑S6linitynarict 8 n 25 11, FILTER SAND #2
OAquiter Test OStornmaterDnirargc
n. h,
OExpetimenpti T`leehnology Osabsidcnee Control
❑Geotemhnl(Closed F�,,i)R)f °it71OG ESMIirtf trea�slttacctx5n
Loop) OTracet FROM To aF�CRIrirON e»ta,t•'t,ara cn%FnmeA tto�ttr.
❑Geothermal(Hea' attCootl Return) ❑fhher t ain under 421 Retnalim h• tL
fL n.
d.DateWcll(s)CompIdW.* 10-20-21 �typ"M#TMW-3
rt, (L
54.Well Location: n, fL
South Boulevard Assemblage
Faei)fW1M,=Nume Factliq 1AaC[app)xablej n. n
I
4001 South Blvd., Charlotte, NC, 28209 n, h, 0 V 1
Pln'skd Address Cih:.nnd Zip 27RL`MAtt1C5 -
Mecklenburg 11 temporary well
C;oum), Ptartcl 1deinlreeAtion No,(NN) i,r MAT10A!PRIIC
Sh.i atitudc and 1Anj;tttde in degmeslmimucslseconds or decimal(legrrm 22,Certilrcatiom
illxaii.field,ane.latfl6ngislatlf lt(4)
)! W o _ - 10/
�. 24/2021
Sign3niicof '-'—t:�.�•�ZA�R-m--.,r _.Daft
..._
6.Is(are)the wdl(s) t3Petmaneat or zTemporary
M'.17�Af/i`�AaY�irlYa. ,'�:'. . .r�..cr�..ecrt cviut�artred fn urearlm�ee
ivlrle!SA NCAC 02C 1C.P10P N'rt1 Ci+rstrxelr SWjarda¢tul%mutt et
7.Lc this a repair to an existing wcil: ❑Yes or N No rapt of dtU word tars berry pras14r1rd to Mr WO fmmater.
If lhla is a repelr,f if yea_bmim well eonowittmr tit fomwrkm rut rxplain Mr nararre of the
reMir ander*?I rrwm&rsrrfim or an Aw bark of this farm 23.Site diagram or additional Heil details:
You nM,use dB back of this page to pro%$de additional well Site details of aell
8.Nutubcr of wells constructed: 1 eolutmction details. You may also attach additional pages if necessan.
For nwiWprlt lowkma-or ium-%wwr algfd.v aa'llr ONLY"Wit der wme torlsPw1bn.W'*ram
A%&11ft6W fora SUBMIML]INSTLTC'ITONS
4.Total well depth below land surface: 25 (B,) 24a, For All Wells: Submit this form %%ithin 30 d4.vs of completion of well
FormWAplr nylls lis►atil deprtks tfd*retn(examaptr-3u?`ZW'oaad 2@ rlttr) construction to the following:
10.Static cater level below tots of racing: (ft.) Division of Water Rego artts,Inf r mation Processing Unit,
If itiamr Irarel is rebore mang, 1617 Mail Service Center.Raleigh,NC 276"4617
t 1.Borehole diatnetar:2.25° (fa) 24b.For tnttxttnn Webs ONLY: in addition to sending the form to the addnw in
249 above. also submit a copy of:this form nithin 3t)days of conmpletion of Hell
I2.Wdl a mstroction metbod:DPT co laniction to the following:
lie.auger:amity.cibl`'dins'pnk cta.) Division of Water Resources Underground Injection Control Prof ram.
FOR WATER SUPPLY WELLS ONLY- 1636 Mail Service Center.Raleigh,NC 276991636
111%livid(►rpm) Method of test: 24c.For Water Sulal 14r In od ms Wells:
Also submit one copy of this!Orin within 30 days of completion of
131a.Disinfection tom, Amount' well construction to the county health dcpattment of the coamty where
constructed.
FansG%yt North CamlinsDtonnciaofF.m•itonme%and MrurslResotms-DiAslonofSNaterReaiarar Rm-1sedAig st2013