GW1-2022-03301_Well Construction - GW1_20220314

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WALL CONSTRUCTION RECORD �\\_C/V' ForincmiILizcONi;v:
This fornp can bc,used for sinrk or mullipk w dis
1.Welt Contractor Information:
J J4.WA?ER'LONM
Stefan Smith FROM TO DKSCRIPTlt N
Weil Coi tragor Nana
3576A
NC\\'cllComractorCcnificationNumber 15.OUTERCASINGOarmulikescdw"s OR41N41t it"a IkaDk
FROM TO DIAIMETER" TIIfCKi\EgS -�1ATF.RIAL
SAEDACCO inc 0 f1. 57 (1. 2 in. 40 PVC
I:an1pully Name -16ANNER CASING'OR TUBING(tiewbermaf closed-look)
)
FROM _ TO DUVVIF'TER. I THICKNESS MAITRIAL
2.Well Construction Permit fJ: h. 1 ft.
List till applirable uelf prnrritr(i:r.C,nunte..St:9 r..Vwriarteq Ireacdal eti.)
in.
3.Wet Use(check well use): J SCRCCN
Water Supply'Well: FROM I TO I AIAMF.Tr it w+ MA)TSl?Y_ NIATERIA1,
OAgricuttural tSMuoicipaMtbtic 57 h. 67 h. 2 i^• Olo 4o PVC
OGeothcmtal(ticatingtooling Supply) DResidential Water Supph'(single) A. tt. iti•
CllndustriaKoninicrcial ORcsidential Water Supph•(sharcdl All;GROUTFROM To MATERtnI. EMvr ACEMENr IN1Frrloo&Armouyr
❑irri rition 0 ft. 52 ft. Portland/be 6T=dte
Non-Water Supply Well:
6ohtonitorintt ❑Rccowrry
injection Well:
ClAquifer Recharge OCyroundnatcr Rontcdialion 19.SAND/GRAVEL PACK fit dicable
FROM -10 MATFRIAI. I MPLACr w1E\T N1Tr1Otp
❑Aquifer Storage and Rccovcty ❑Salinity•Barrier 55 A. 68 ft. Sand ` 2
❑Aquifer Test 05toriniviter Drainage f1 ft.
0E\Terimcnhtl Torbnology ❑Sahsidcricc Cgmrot
%20:"DRB,f.INC LOG(attach additional sbects if neccicutni`-
❑Ckothennal(Closed Loop) [)Tracer FROM To DFSCRIPTtONftubr.hr,ronccs,sntl'mckh 'ri!6te.Nt.i
❑Geothennal(ReatingiCoolineRetuno ❑Oilier(es lain onder 021 Rein,&-) 0 ft. 33 ft. Sandy silt
33 ff. 68 (t. PAIR
4.Date WOWS)Completed: 1-4-2022 Well iD#MW36T
5a.%Vcll G►cathm:
Camp North
Facilit,'OwncrNome Facility IDB(irappli;Sblc) ft. ft.
1824 Statesville Avenue Charlotte, NC 28206 Meckle, A. h. MAD 9 4 !10
Charlotte, NC, 28206 Pinsi`at Addmss,City,and Zip 21 RDIARK.0 �1 ¢ L
���/'�� 3 foot bentonite seal from 52 to, 551
Cnrurr_ , ihlcel Idrniifiscalion Nn.(PI\) r,-
Sh.l,atitirdc and Longitude in degms/minutcs/secondc or decimal dcWVcN.: 22.Certification:
(ifocll fictd,9t►.1at16lig ist:ldlieicrA)
80.830981 2/14/202235.248916 � a
Slgrutt ofCcYRcdNdlConttuctor Dalc
6.Is(are)the well(s): MPennanent or DTemporary
M.aigning this fifmm I frerrhr t'err)fr plan Mr wril(si way(werr)eonvin,cled br rrccordanrr
wirlr l f%,VCAC 02C.Ill(x)or l SA N01 C QC.rf200 Well Corrorrarrkol Stolyk ads anti rhat a
7.Lc this a ripair to an existing well: OVec or MNu rYf,y of th)s rrrnn'I hm,hint(trrfl idrd to)ht Sn ll m_ t nrr,
If this it a hlmir,fill two,knawa welt t ntrstnirolan infomttriltm and eiplohl dw turrnre of the
relvir tnrrler Alf rrnrarkv sesr!&m or at drr hrtrk of thin'firm. 23.Site diagram or additional well details:
You only use tile,back of this page to provide additions well site details or well
8.Number of wells constructed: consuuctiondetails. You may also attach additional pages if Iktiessar)'.
For rtu,h)p)e iofe,4on&arm-waver snpj>%wells ON/1',virh the same ronsrruelion,you e.9n
suhmir nne form. SUBMITTAL I IUC.TTIONC
9.Total well depth below land surface: 67 (f4) 24a. For all Wells: Subuil thi's fonn within 39 dsw's of completion of,fell
ror otatttipir wells list W/(fe.ohs if dl0rew lextr p(e•_t02(O'teal 2c IMI constnectionto the foltowing.
10.Statte water level below top of casing: (n•) Divishm of WitterResoumes,Information Processing Unit,
lfioatet levy)is above rai4q,as,' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.6 (in) 24b.EgI In 1ec11on WeI1c ONIN: lit addition to sending the fora to the address in
24a above, also submit a copy of this form within 10 days of completion of well
12.'sVell construction method: Sonic construction to tile followinel
(i.e.auger.rowan•,cable.direct push c1c.)
Division of eater Resourms".Underground Injection Control Program,
FOR WATER SIbPPLV WELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699-1630
r
13a.1idd(t:pm) :Method of test: tic.for Water Supply&injection Wel1c:
Also submit one copy of this faun within 30 days of completion of
13b.Uitinfitixion type: __ Amount: _ y _ _ %veil construction to the count} h�atth dcInntnun of the county.where
- constructed.
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Fonn GW-I North Carolitu Dcpannicni of Environuncin and Natural Resources-Division of Watcr Resotrom Revised August 2017
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