GW1-2022-03293_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For ltacriun)Use ONLY:
This forn can lx used for sinfcic or muhip)c wdis
1.1Yd1 Contractor Information:
Ii.��rw�R 20N>rs.
Stefan Smith FROM TO DFSCRIPTK)N
Well CordrictDt 7�1 ft. fl.
6
3576A
NCnrcllCommoorCcnifaat ion Nwibcr '1S.OtiTERGA5ING fornuhica�alrells"ORL1iMER Na Ikabie'
FROM TO DUMUTF11• TIiICKNF," MATERIAL
SASDACCO Inc
0 f1. 77 ft. 2 to. 40 PVC
(;migrutl t35nif tfi:1INMER CA817VG"OR:TV8lNG'4 eothennat clo>xd t7ti`
FROM TO DIA1tETER T1rCKSM. MATERIAL
2.Well Construction Permit ti: ft. ft. _ � _ _
list aft applirahle well pronits(Lr.C•nun(+:SM,,hr..tnrianre,.14a tiat eir.) .rl ft. - in.
3.Weil list(check well use):
Water Supply Well: FROM I TO I DIAMETER I sl Tsiir. TnICK+rL I MATERIAL
41�1grieutnual MunicipalfPttblic 77 ft. 87 ff. 2 ip. 010 40 PVC
0Geothemtal OicalingfCooling Supply) i311esidential Water Supph•(single) (t. iL in,
OludustriaMouinicmial (;)Residential Water Supph'(stared) goy OUT To' )InTERtnt, EMPL%CFMLNT\fF Tt10D fi AMOUNT
Diri •nion 0 h. 72 fi. Portland/bAEnemfe
Non-Water Supply Well:
ft: fr.
lmmonitoring Dltccovery
Injection Well: (I. ft.
❑Aquifer Recharge 13
Gromndvs-mcrRenicdiation 19.StlNblGR,WFL—PACK(if ilicafilr) '
FROri. ti.,pi.ncr.ir..r Nt:Tnnn
❑AquiferStongc and Recovery ❑Salinity Bam TO �inTr:Rtat.cr 75 R. 88 ft, sand 2
❑Aquifer Test ❑Storm%xiler Drain)gc .
OEytcrimcntal Technology O.Subsidencc Control
20:1)RILidNGIOG(01achsddhionAtthM&ifn&6c iry
DGeothennal(Closed Loop) DTracer FROM TO DFSCRiPTION robe hardnrr:vaenwko a s c.4*.1
❑Geothennal tlleatinglCoolinge Mon)) DOtlter(in fain under#21 Remarks) 0 ft. 57 ft. Sandy silt
57 ft. 77 ft. PWR
4.DateWe11(s')Complcicd: 1-25-2022 W(qtIDgMW34T 77 ft. 78 (L Rock
l
5s.Well Location: h. ft.
Camp North h. ft. AR 1 2p ?
Facl t,%I +trr Nanic Fac(lii`1DX(if appii aAlc) A. ft.
1824 Statesville Avenue Charlotte, NC 28206 Meckle, ft. ft.
Charlotte, NC, 28206 Physical Address,City.and Zip 2t;R�h1ARItS `; '
3 foot bentonite seal from 72 to 751
toroth Parse)U.mifiGaion N(-,(PiN)
5b.1.4ditude and Longitude in dcgnxc/minutcs/seennds or decimal degrees: 22.Certification:
(itut*il field,one libleM is sat iei nn
35.245909 N 80.833395 W 2/14/2022
Sigrtat' of Cc.fret Wcll Contm,tor Date
6.h(are)the well(s): XIPe nianent or oTemportiary l3+•signing Ws fit+n,I hereb,,eerlifi rh�!hr nr1113)wtts(urn)i'[i liyrt[yeti ire e.YY oYrlV ee
idth 154 XC-AC MC,t3W or I M ACAC 02C,0209 Well 6nrorrit rion Stonl4aleft and limn!ri
7.Is this a repair to an existing well: oYcs or �No rcgiy of this reron't hat horn l,trsefd dl to'the in•11 miner,
if this%i a lr'lxlfr fill rat:1'noirVi urld ronstturtrmt tnfrmrutrion and erpluin rbe nature of the
rejtair airderP21 A.,norkr-%frown ar an the hm l of diLv form. 23.Site diagram or additional+ve1l details:
You ma)•use file bask of this page to proOde additional well site details or%veil
8.Number of%veto constnicted• construction details. You may also attach additional pages if necessar'.
For mtdliple InJ<Ydmt vt urM1i-fearer supple•ioelk ON/1'ti•ldr the some consrruedor,ymu<wn
sutn,urone form. SIJUMITTAL l`i STi1CTIONS
9.Total well depth below land surface: 87 (ft.) 24a. For All Wells: Submit this-form within 30 days of completion of well
For ittalliplew0h list all deptitrtjdifterrnt(cxmnpfe•,?G 2fi!)'tt>kl20llXt) constnictionto the foltoaing:.
10.Statie water level below top of casing: (ft.) Dh ision of Water Re ources,Information Processing Unit,
if ieatef level is ahore r-astag,toe"=" 1617'stail Service tenter.Raleigh.NC 27699-1617
11.Borehole diameter-6 (in.) 24b.For lnlcrtion Wells ONLY: in addition to sending the form to the address in
243 above. also submit a cope of this'for'n lvithin p days of completion of well
12.Well construction method: Sonic construction to the following;
(i.e.anger.rotan•.Gable.-dirca pustt etc_) f. -
Division of Water Resources,Underpvund Injection Control Program.
FOR WATER SUPPLY WELLS ONLY• 1636 Mail Service Center.Raleigh,XC 27699-1636
13a.Yield(gpm) Method of test.• 24c.For Water Sopaly cYt InLcctam��clts:
Also submit one copy of this form within 30 days of completion of
136:Disinfection type: Amount: well constuction to the county hclhh dcpadmait of the county whcrc
constnicicd.
s
Fono CjW-I Nonh Carolina 0cpznm m of Em ironnletti and Natural Resources-Division of Aratei Rmtrees Revised August 2013