GW1-2022-03300_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For lticnial Use ONLY:
This form can k used for sinpk or m llipk wells
I.Wdl Contractor information:
14.WATER ZONCS '
Stefan Smith FROM TP DF:r'(;RIPtION
Well Citmrtat)r Naitte
fl. ft.
3576A
NC�1rdl ConitactorCcnifnntion Ntimbcr IS:OUTF.R CASING ttorimutl14s ed w0s OR LiNER it;a Ikyble
FROM I TO MAMM, .R- TiliCKN'EI'S MATP.RIAL
SAEDACCO Inc 0 ft. 46 It. 2 in. 40 PVC
16.INNER ING OR T11ti1N itbcrm G";►rat closed luojti'T
<aagt5n)'N uk FROM TO I DUIIETER TIIICKSESS MATTRiAL
2.Well Construction Permit In.
lift till applirelblr well prnnila(i_r.C.•as(nry:Simtr.Variance,lrisr6crt err.) ft. fl. In.
3.Well lice(check well use): 17 SCRUN'
Water Supply Well: FROM TO DIAMETER SI.OTSI71 Tt1I(K\l1� MATERIAI:
ClAgricaltural 0Municipallhiblic 46 fly 56 fl. 2 in• 010 40 PVC
OGeothcmtal(Ncating/Cooling Supply) OResidenikil Water Supph•(single)
p(ndustrial/Conmtcrcial 17Residential Water Supply(stared) 8.GRO1fT
M To MATERInt, I F.AtP1 ACF Mi NT>tt`t110o fi A 11011\T
Ofrri ation r19.0SANDX1RA%#
It. 41 It. Portland/bArveAte
Non-Water Supply Well:
tomonhorin, ORccosrty
injection Well:
0AquifcrRcchargc OGroundwatcrkincdiation ILI'ACKIJ ltkafilr
FROM 1 TO 1MATI;RI,a1, EMPLACIA NTM171100
❑AquifcrStorage and Recitirtn' ❑Salinity Hanicr 44 p. 57 fL Sand 2
❑Aquifer Test OStorrnm-atcr Dron,9ge ft h
❑E%:prrimcnlal Technology Otiuhsidcncc Cots rot
'2orDRHAANG LOG 7atlxh additional skcHs if neemsiril
OG:othemtal(Closed Loop) OTracet FROM TO DESCRIPTION'((rota hsrdneti rti-lYrncktc in tbk.Csr.l
OGeothenilal04catingtoolineRetain) OOtherlexlainunder#21Remarks) 0 ft. 41 try sandy silt
41 ft. 56 ft. PWR
4.Date WCII(A)Completed: 1-6-2022 WdI1D#MW31T ft. fL
Sa.Well Location: ft.
Camp North ft. ft. AAA
FacIityAhvricr,lnntc FacilitylD9(if applwhic) ft. ft. Ffg�R
1824 Statesville Avenue Charlotte, NC 28206 Meckle, tt. R.
Charlotte, NC, 28206 Pin s'+calAddm.is.City.and Zip 2t RCMARIi$
3 foot bentonite seal from 41 to 44''""
(:Dinh' Parcel Uall mliunNo.(PiN)
Sh.Latitude and i onRitudc in degrecslminutciAccondsor decimal degrees: 22.Certification:
(if cell Acid.one b0otig is Stdlieitid)
35.248617 N 80.834746 fjY m 2/14/2022 R
Sierc7t: ofCckitrd�4dlContmctorM Date
6.LS(are)the well(s): Permanent or oTemporary fJ Signing•this firnn,l heals ierfi#dull the rrell(s)uwS fwrirl i-oli rr»cred bt tweendant'r
n'ith 15,1 XCAC 02C.01(k)al ►SA N61C i12C:02M)1441 Const"Clion s4rry4illils anrJthru a
7.Is this a repair to as existing well: O Ves or O No ropy aftdir reranl hies hr wt Ptnr&T•d'tn Ow w11.»vner,
1f M4 if a fgmir'fill ixu kno4m u'rli ceownmtlnn btfi�rorwan and eeplohi the rutmre of rbr
rrlmir um9rr g21 rrmark.r srt'Nan ni cm the irrti•k of diir fiirrn. 23.Site diagram or additional well details:You may use file back of this page to prot'ide additional well site details or well
8.Number of wells constructed: coustruction details. You n)aj•alto attach additional palvs if ivecessary.
For muhlple isle orlon w argFatvrrer suPp�v irells ONLY++'idt(lie saMr eonslruellon,;con Cow
sui nit one form. SUBMITTAL INQIUC-333ON
9.Total well depth below land mirface. 56 (ff,) 24a. For All Wells:. Submit this fonn wilhiu Sit days of completion of troll
Far maihlple tolls lin01 delnhs lj dif rre'or(rxmnalC.i4nXt1!)'i1n t 20.100) construction to the follo%%ing;
lU.Static avatar level below top of casing: fn,) Division of Water Resources,Information Provc4 Ting Unit,
n et!evil 1a alwwe rtistag;inw"i" 1617 Mail Sen'ice
ift C:eater,,Ralcigh,NC27699-1617
11.Borehole diameter-6 (in,) 24b.Ur Inicctloo Wells ONL%':: lit addition to sending the fonts to the address in
24a above. also submit a copy of this fotm within '0 days of completion of tell
12:Wcll construction method: Sonic Construction to Cite following! f
(i.e.wiper.rwan'.cabic direct push eta)
Division of Water.Resources,underground injection Control Pmgrany
FOR WATER SUPPLi'WELLS ONLY: 1636)11ni1 Scn'icc Center.Raleigh.\C 276994636
1.
13a 1'ieid(Pm) �1cthod of tact �•For Water Suppi>&'Injection Welts:
Also submit one copy of this form within 30 daysofcompletionof
13h.DisinfeaTinn h'pc:- Amount:-. _ .. well construdion to the county
hcahh dcp anmau of the cotmh.it'I►crc
constructed..
Fonn G11'-1 t`'orth Carolilta 6 Resourcm Revised August?U 13