GW1-2022-03295_Well Construction - GW1_20220314

WLLL CONSTRUcriON RECORD For internal Use ONLY:
This form can be used for singk or multiple stills'
1.WdI Contractor information:
I&WATER ZONES•
Stefan Smith FROM TO D_'CRIP110N
IFe11 ConirlgarNantc p. f1.
3576A
NC Well Contractor Cenifnaiion Number 15 OUTER CASING-(for inuhtWsWq-vi s-0R LTNER if a kable
FROM TO �DIANIETFR= THICKNESS MATERIAL.
SAEDACCO Inc 0 ft. 12 ft. 2 ;in. 40 PVC
('„angnauy'NSnrc 16-1NI!IERCASING OR TVBING f ealbermal etowd400p
FROM TO DL4NtFTER THICKNESS MATERIAL
2.Well Construction Permit N: ft. ft. in
list itll applicable µ'elf liTi+niaf(ier.('nurrh:.SA7te.l'arirrrrce,7ayatial ue.) ft. ff. tyro
3.Well Use(chat:well use): 17 SCRI!N
Water Supply Well: FROM I To I DIANIFTER I SIJOTS17E I TIIICKNFN% I MATERIAL
47Agricaihurai. i municipoVlstiblic. 12 ft, 22 ft. 2 ie: 0l0 4o PVC
OGeothcmlal(ticaiing.'Cooling Supph') DResidential Water Supph'(single) ft. ft. in
DindustriaUConmterciai nitesidential\triter Supph'(shared) i`'CROUT OM 1 TO MATERIAL i P.\Tl+i tCTMGIT METHOD fi AMOUNT
❑lrri otion 0 ft. 7 ft. Portland/benTn®te
Non-Water Supply Well:
A. ft. I
6htonitorinfi DRccovery
injection Well: ft. ft.
OAgnifer,Rechargc 06rouMvvlterRcntediation 19.SANDWRAVEL PACK(if llkible
YHOM. I TO I N1ATFRlat. F.MPt\C"IENTMI7FInD
❑Aquifer Siomgc and Recovery ❑Salinity Barber 10 A. 1 23 ft, Sand 2
OAgnifcrTcst ❑SmmiwatcrDrtinaoc ft ft
bExperimcntal Technology OSubsidcncc Control
'20:DRp,L1(�"C 1:AG:7altacb additionet ahetls ifntres>an
DGeothenwd(Closed Loop) DTracer FROM TO DESCRIPTION(tvbr,hor0net+u0nick t+ ri-die.4ft.1
DGeotheunal(Reati ngatooli tie Relum) DOdler tcx lairs under#21 Remarks) 0 ft. 23 ft. Sandy;silt
tt. ft.
4.Date Well(s)Completed: 1-14-2022 WdIID#Mw38S ft. (L
5a.Well Loeathln:
Camp North ft. ft. �# �n
Facility.?Ownc.rNan+c Fac7itrfDkfi[appliablc► fi. ft. M 4 20'2?
1824 Statesville Avenue Charlotte, NC 28206 Meckle, ft.- fL
Charlotte, NC, 28206 Pin'sical.Address.City.and Zip 31 RtiMARI
3 foot bentonite seal from 7 to 10'
CGnanh' Parcel tt1:•alirtGrdun No.(PIN)
5b.Latitude and Longitude in degmcstminutcslsecondc or decimal degrecs: 22.Certification:
(if++ru kid,one l.w1ons it:mdtici:in)
35.247200 N 80.832688 W r 2/14/2022
Sigmr of Cc:Ifw^d W'ctl Contractor Date
6.16(are)the w'ell(s): 111 ennanent or OTemporan' M s;gnimp this fa tm.I hereby e,•rrifk dirt Me warftfs')tivy l m*irt f'lrril'IHretetl in 4Wr'PrdanCe
with 154 XCAC 02C,0199 or 1st n'Gii^mC.n200 Well Comma tine Stan(1Qr715 tout tharr a
7.Is this a repair to an existing w'eil: OVec or CM rrVygfdrir rtrorvl has kern pn*fde4 to the sty ll tntner,
If this it a repa9lr,fill rxtt kori,rtn well awtstrtrtalon lirfomwilon and explain dw nnrnre of(for
rtlmir tnr.9rr ir21 rennrks sr.•riem nr cv1 rhr bar.E of fills farm. 23.Site dial;ranl or additional well details:
Iron may use tlM back of.this page,to provide additional µ'ell site details or well
8.Ntember of wells consintcted: construction details: You may also atlach additional pages if nea:e"ary'.
For mnhlrle JoJer4on or nrrin•fearer supple noeUs OjVI 'midi the some eonstrnelloir,yogi am
salwnir one form, SUBMCPTAL INS9'i1,C,TIONS
9.Total well depth below land stirface: 22 (ft.) 24a. Hot Alt Wells:. Submit this form %ithin 30 days of completion of well
ror irrlddprr tartly l(ts nt1 dettths ff diffrrew(example-02W and 20 W) construction to 111C following;
10.Static water level below top of casing: (ft.) Division of Water Resourceµ,Information Processing Unit,
lf+twee le+el h 01'0+1.•ending,tale"<" 1617 Mail Service Center,RalcW N(:276994617
11.Borehole diameter:6 (in.) 24b.Far[itlection Wells ONLY: lot addition to sending the foal to(lie address in
24a above. also submit a copy of;this form within 30 days of completion of well
12,Well construction method: Sonic construction to the following
Re.anger.rotary.cable,direct push etc.)
Aivision of Water,Rcsoun'cs,Underpr'ound Injection Control Program,
FOR WATER S6PPL1r♦ ELLS ONLY: 1636 Mail Service Center.Raleigh,NC27699-1636
24c.For Water Supple&Injection Wells:
13a.Yield(Rpm) Mrdigd of test r
Also submit one cop}' of this form within 39 da}'s of completion of
13b.11114infictiunIV a .__.. __.- Amount: __--__ well construction to the county hcallh dcpanmcrn of the crntnh.wltcm
P . f
constnrctcd.
Form GW-1 Noah Carolina b.-parintatn of Environment and Naunral Resources-Division of Waler Resotrbes Revised:august 201.1