GW1-2022-03291_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For ltacnul Use ONLY:
This forincan be used for stngk or multiple seals'
1.Well Coniractor Information:
i_WATLR ZONCS
Stefan Smith FROM To DESCRIPTION
Well Corirtacwt i\ ttw h. A.
3576A
NC Well ContractorCenifi ation Number '15.O111TER CASING:for atuhi4tikil wells OR LINER-it:a "licahle.
FROM TO DIAMETER THICKNFSS I MA7TRIAL
SAEDACCO Inc 0 ft. 8 ft. 2 `in. 40 PVC
Compain•t laic 16 aNYER' ING'OR T)BING eotber nal closedaon'
-FROM_ TO DLAI R TiIICKNF.Ss A1ATf.R1AL
2.Well(7onstruction Permit fi: A. ft.
1.iv all nlrprlirable welt prnnitx(Er.C6jmr.v'S6hr.-Variatwe.iY#a0b1 rrc.) fl. U. -�- in•
3.Weil Use(check well use): 17 SC M-R
Water Supply Well: FROM I TO AIAIMETER Stmsirx I MATERIAL
❑Agticnitural 0municipalillublic 8 ft. 23 fl. 1 2 in, 010 40 PVC
❑Geothermal(HC3IikPX00liog Supply) I311csidential Water Supply(single) fI. ft.
0Industrial/Conmtcrcial 011csidential Water Supph•(s147rod) 1Is.GROFROM 1 UT To a1nTl RtA1. I @MVIACI MG\T.Nrrrlon.e Ai,nuNT
111ni anion 0 ff. 4 ft. Portland/betnTn811ite
Non-Water Supply Well: A. A
6 monitorigg ❑Recovery
Injection Well: A. ft.
❑Aquifer'Rcchargc OGronndnhtcr Rcowdiation 19.SANDIC RAVI L PACK(if 41411kabW
FROM TO AIATPRIAI. F:J1P1..\C'i;111:�'r Mr7HO1r
❑Aquifer Storage and Recovery ❑Salinity Harrier 24 ft. sand 2
❑Aquifer Test ❑Stormwater Dlainargc ft. ►I.
❑E%perimcnMI Technology ❑Subsidcricc Corbml
20,'DRp.L1NC"40Gfatlachaddiliomalntucets`ifaucc�san• -
❑Cteothennal(Closed Loop) ❑Tracer FRoat TO DFSCRIPTIO\ (ubr.liaronec.wtrit rkre n arc,Nc:l
OGeothennal(ReatinelCoolina Return) ❑Other(explain under fi21 Renmatls) 0 (1. 24 ft. Sandy silt
ft. ft. _
4.Date Well(s)Completed: 2-22-2022 W(qlm#Mw47S
h. u. -
5a.Well Li►cathm: ft. ft. MAR 14 �
Camp North fl. f1.
Fac7ityXhvrrr Nan+c Facility IDN(if appli:.61c)
1824 Statesville Avenue Charlotte, NC 28206 Meckle,
Charlotte, NC, 28206 Physicnl.AddmscCitr.andZip 21:RIMARICC':;
2 foot bentonite seal from 4 to 61
(.:annh PaiCel U-ni ificnion No.(Pi\)
Sb,iartitude and Longitude in de.g/ecs/minutcVicennds or decimal degrees 22.C:crtilieation:
(if sell!'scud,one kdloq is sidlickpo)
35.248193 N 80.832408 K' _ _ _ _ �... <.r. 2/27/2022
Sirfo of CeYfi d Wcll Conowlor ry Dare
6.U(are)the well(s): :fPermanent or DTemporan
tJp 3igninf•lhis,(i.trn,1 hereby rrrrifs•that 1hr 1iC/t(.<!turps{Wrrr)eorictnrcrerl bi!•.Cordonre
mitt(!1,t NCACO2C.01(k)pr 15,f ketC 02c;0240 Well Calrstrrrerion SrdrL#rrels told flint a
7.Is this a repair ft)an existing well: oyes or zNil ropy nfibisrecmYlhasbei-11pnn•ldrdtojhrswillmoirr.
If rhIs it a felxdr,fiat per•tar;1m well crtutnrcrinn hiforeutriort grad eeptnirr rbr rut rare of rbr
reltairtorder0?1 rrrnarks.wr-jiorr or an dir hrak of Mix form. 23.Site diagram or additional welt details:
You tna)•use die back of this page to provide additional.well site details or well
8.Number of wells c6ftstrueted: construction details. You'ntiv .also ilttiieli additional pabses if iweessarv.
For rrnddple 1'o(eeih>n or n-@Us OrYLY with dry sorne-eonstrucrion,you can
sabmitone form. SUBMITTAL WSTCICTIONS
9.Total well depth below land surface: 23 (ft.) 24a. For all Wells: Subunt this fonn♦%ithin 30 days of completion of%yell
Formaltiple icelk list all depths!j diftcten((esmnp(r•3@2M'and 20 li>fp') Construction to the folto%%ing;
10.Static water level below top of casing' (ft.l Division of WaterResaurcm Information Processing Unit,
Ifismer level is ahoy casing,w4,".^ 1617 Mail Service Center;Raleigh,NC 276"4617
11.Borehole diameter.8 (in,) 24b.For Inkrtion Wcils'ONM j lit addition to sending the font to the address in
24a above. also submit a cop) of,this fonn within 3O days of completion of well
12.%Vell construction method: HSA construction to the following,
(i.e.anger,rcaary.cable.diteati push etc.)
Division of Water Resources.'`Underground injection Control Program.
FOR WATER SUPPLi'WELLS ONLY: 1636 Mail Service Center.Raleigh,\C 276".1636
13a.Yield(S pm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one cop), of this form within 30 da)sof completion of
13b.UlAinfaKiun type: Amount:_.__ well construction to the county health dclnrinm)t of the anmty.wlicle
constructed.
Fofill CAN,-I Norio Carolina fAganinem of Emiromiciu aitdNatnral Resources-Division of%%laterResotm Revised August 2013
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