GW1-2022-03292_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For l,acntnl Use ONLY:
This form can to used for sinFtc or mullipk wells
1.Well Contractor Information:
44.W ATERZONES
Stefan Smith FROM TO FI SCRIP'"ON
%Fell Contrictot t ale n. n.
n. ft. l
3576A
NC Weil Contraelor Certification Number 15:'OIITF,R CASING(for' uhit'_ ' Wdnls)OR LiN"IM if i `Ikahk
r-.I6JNN;FRCqA&SINGOR-
O DIAMETER- TF11CKNFS5 MATERIAL
SAEDACCO Inc n. 2 in. 40 PVC
Nnine
TUBING eothO DLAtIF.TER TIIICKNESS MATERIAL
2.WWell Construction Permitll:Gn till applicable writ peirnits lie.G•rmnlh:Sf rtr.1Arinn;4/f�cYOdl[ff.) fl. in.
3.Well[lie(chock well use): 17 SCREEN
Water Supply Well: FROM I TO I DIAMETTA N.OTSI7E I Tl110(Ntas I MATERIAL:
0Agricullufill 0municip:il/Public 7 ft. 22 ft. 2 in, 010 40 PVC
043cothennil(licitingtooli kR Supply) ORcsidcntial Water Supph•(single) n. ft.
OlndustrialfConmtexial 011csidential Water Supph•(shared) FROM 0 TO MATFRIAL F.NtP1.ACEMnT\/FITIOD&Ab1011NT
O tri alion 0 ft. 4 tL Portland/behtmixite
Non-Water Supple Well:
n: n.
whionitoring ORtxovcrg
injection Well:
OAquifcr Recharge 06rounduhtcr Rcmcdiation 19.SANDK.RAVEL PACK7if ilkable"
F
❑Aquifcr SIor,Igc and Rctntrty ❑$alinin•Flarricr FROM TOT M&TF.RIA14 EMP1A(3:MEVTM#-"15 n. 23 A. Sand 2
❑Aquifer Test OStomtssater Dratinarge n. A.
OE\Ilrrimcntat Technology OSubsidcncc Control I `
20,DRILUNG%LOG(altaeh additional sheets if naessan•
❑Geothennal(Closed loop) OTrdcet FROM TO DFSCRIPttON itobr,h»roni cs s,tl'mekN d.lfc.lte.t
OGt:othenna)(HeatinefCooline Return) 001her(ex lain under#21 Remarks) 0 ft. 23 ff. Sandy silt
It. n:
4.Date Well(*)Completed: 2-21-2022 Well ID#MW46S
5a.Well Llicatitm: to. ft.
Camp North f1. ft.
Facilii),'Uvwr Namc Faeilgg ID9(if applieablc) fl. ft.
1824 Statesville Avenue Charlotte, NC 28206 Meckle, ft. ft. -
Charlotte, NC, 28206 Pla'sical Address.Ciq°,and Zip 21 R!(ifARKS
2 foot bentonite seal from 3 to 51 _.
Caauty Parcel Wfairy-11ionNo.(PI\)
5h,Latitude and i.ongitude in depwr4minutes1seeondcor decimal degrocs: 22•Certification:
(ifwell field,offe l:nllonS i%Radlici rd)
35.248244 N 80.831629 WW' 2/27/2022
Six t. of Cek fud j4'cll Conlrn;tor Date
6.is(are)the well(s): ,Permanent or OTemporarp h,-sipmng this ficom,.I herrhr ierfifr dim Me veffs)mws(Kerr!,)roamucted M mLeonhmer
trlrh 1 t t NCAC 02C.010)ar!t,1 A'ClC n2C:02Ao a ell Owstm'rim Sromfirrits and dulls
7.1%this a repair to an existing well: 0Vcs or zNII r'apymj'thisrrcnnihn�hrtr/ti;nlddtolhrHri!fmrnrr,
it ih(s is R reludr,fill the,knnNfl tr4$1 fOrU7nfeilnN information tend explain rbe 1wrure of rite -
rrlmir amlrrP21 remarkrsmefimr ar an fhr bark offhis forni. 23.Site dinilram or additional well details:
You ma)•use the back of this page to picedde additional well site details or well
S.Nuotber of wells constructed: _ consltuction details. You tray also attach additional pabns if necessan
f or,nrddple inlecrlon or ntar wmer tnppla wells ONLY trirh the some construction,),*a can -
rvlmiftinefnnn. SUBMITTAL INSIC1CTIONS
9.Total well depth below land surface: 22 (ft.) 24a. For All Wells: Subinit this fornl within 30 days of completion of well
For,rwhiple wells lln all drpd,s if di eremt(example-30200'mewl 2e MY) construction to the foltoaing;.
10.Static water le%vt below hip of casing: (ft.) Division of water Resource*,information Processing Unit.,
tfw ier level is Rh(me onsing,ww'a" 1617 Mail Sen•ice Center,Raleigh.NC 276"-1617
i
11.Borehole diameter.8 (in.) 24b.For Inkrtioll Wells'ONLV to addition to sending the form to the address in
24a above. also submit a copy of this form within 30 days of completion of well
12.WWrcll construction method: HSA construction to the following
(i-e.anger.roar),.cable direct puck etc.)
Division of Water Resau revs,IInderpvund Injection Gontlril Pmprant,
FOR WATER SUPPLY WELLS ONLY: ]636 Mail Sen•ice Center.Rnleit h.NC 216"4636
13a.Yidd()rpm) Method of test. 24e For Watcr.Supply&injection Wells:
Also submit one cop)' of this form within 30 days of completion of
13h.Disinfection type: _ Amount: well construction to the county licalih dap frinlatl of the ernmh.whctr
consmtctcd.
f
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Fono Gw-1 Noll Cawfli a Dcpanntent of Enk ironnrm attd N:ittiraI Rcsourees-Divsioo of\Vaici Resowm Revised Augu9t 3/i 13