GW1-2022-03302_Well Construction - GW1_20220314

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VVELL CONS`1'I2UC`rm RECORD For IitcntalUscONLY: t
This Conn can be oscd for single or multipk iwils'
L.Well Contractor information:
fl"A7LRZt)NS
Stefan Smith FROM 'to I nFSCRIPTION
Well Corrtaciot,Nafiw N. ft.
3576A
NC NAteliConiriclorCcni@cation Nnnbei -'.OUTER CAStZNG t(oi iliuhicasr'.i.14)OR UNER if i Il-bk
FROM TO nMMETER- THiCAN'ESS \1ATERIAL
SAEDACCO Inc 0 ft. 6 h. 2 j in. 40 PVC
(oulp;n y Narttc ,t6.INNER CASING OR TUBM(eotsermattlo rd Itx1 :'
FROM I TO I MCNIF.TER TAICKN SS I MATTRiAL
2.WdlCon5tructionPciTnit
thl all applirable well peewits(Lr.C'ntrnry:Stine.Vari(mce.1/�EYGQrt ui.J
t. ft.f
3.Well Use(check well use):
Water Suppkv Well: FROM I TO MAMMA ti1.07'S1U 711100M I AIATERIAL
OAgricuttural 0municipalfNibtic 6 p. 16 fI. 2 in, 010 40 PVC
Meothermal(IleatinglCooling Supph) DResidential Water Suµph•(single) A. ft.
OlndustriAlConlntercial 011 sidential\411ter 5t)pph(shred) '98':GROIff
FROM I TO MATMAL, r EMPLACT;MFIT JN1M1OD A AMOUNT
❑fiTigation 0 ft. 3 ft. Portland/be)TneAte
Non-Water Supply Well:
ft. fL
6ilhlonitoring ORcccl�r>?'
injection Well:
OAquiferAccharge 0433roundu itcrRcnlcdiation 19.SANDIG"RA�IE PAC Ktif "tlicuAte
FROM. I To MATT rtIAI, F.MPI.,�f:i;Mi,NT MI"I'flOn
DAquifer Storage and Recovery ❑Salinity Birricr fL 17 rt. sand 2
OAgnifer Test 03tormwiter Drainage 5 (1. ft.. ,
OExpcnmcntal Technology OSuhsidcticc Corarol
_120 DRILI.ti�GiGOG"(attach additional sleekNow
OGeathennal(ClosedLoop) ❑TrdUt FROM TO DESCRIPTION aiYmikH' n.Yrc.ea.1
❑Goothenual Meatier tCaoline Return) 00ther(explain under{21 Remarks) 0 ft. 17 ft. Sandy silt
ft. ft.
a.DatcWcU(s)Complc(ed; 2-24-2022 WelliDNOB3
ft. a.
5a.Wellllicathrn:
Camp North ft, ft. 1V1 mix
Fac.Ph lOwner Ninr Facility iDk(if applicable) ft. ft.
1824 Statesville Avenue Charlotte, NC 28206 Meckle, p, ft."
Charlotte, NC, 28206 Pinsiol Address,City,and Zip 21.;RthIAR0
2 foot bentonite seal from 3 to 5'
"penny Patter Idenlirtc16011N6.(PIN)
Sh.i,ntitudc and I•ongitude in degrecOminutcslsecnnds or decimal degrees: 22.Ccrtifitteation•
(if oetl livid,one latlotn;is stdliickrn)
35.247850 N 80.834801 2/27/2022
Stgrur, of cc nf'rd dell Contractor, Daic
6.Is(are)the well(s); IIiPennancot or OTemporary tfr argninp this,feahn,i herein errrifv Mm ilw.vefl.ti"wS fmWm)ear istrueled in tteeordimer
with 1 SA XCAC{)2C.010)en•l M A'CAC(12C M00 Well Cnma7rrn-km Stan4iuds and dial a
7.Is this a repair to an exi..sting well: OYes or fNo ;n•Il r'Amer.
if Chia is a lepoir fill tRn t-wilm wdfennsinrrtion Atf000w ion emd expinht the naryre of the
relarir tnrdrr,921 rrrmr,rk teru m or ran the hmk of rhis form. 23.Site diagram-or additional well details:
You may use tl-,back of this page to provide additional well site details or well
8.Number of wells consinlcted: construction details. You tnay also at(ach additional pages if ttecessenv.
Fur.enalliple Inleelkirt&r e rat-worer smpp>v lsells ONI.F i4th the some conatrucliont tern can
.Mofflirone form. SUBMITTAL.CNST1LC 6NS
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9.Total well depth below land surfacet 16 (ft.) 24a. For All Wills:..Subtrol tliis`form within aft days of cornplctioti of'1he11
For rnyMprla wells list all drrnhs tf difE rew(exmnPle:3 200'dial 2014W) construction to the foltowing;
10.Static water level below top of casing: (n,) Division of Water Resources;Information Processing Unit,
If immet leeel is ahme r-asirtg,use"s" 1617 Mail Service',C'enter.Raleigh.NC 27699-1417
11.Borchole diameter.8 (in.) 24b.For lnicctlon Weil,ONLI: 'in addition to sending the form to the address in
24a above. also submit a ropy of this form within 30 days of complelion of well
12 Well construction method: HSA construction to the following:
(i.c.wagm rotar)%cable.direct push etc-) _•
Division of WaterRcsourccs,Undetground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: i636 Mail ServicejCenter.Raleiµh,sYC27699-1636
13a.Yidd(gpm) Mctbod of test: 24c.for Water.Supely&injmMuon Wolh:
Also submit one cop), of this fond within 30 daysofcompletion of
13b.Ditinfetttion type: ___ Amount: shell consiniction to the county i ehhh dcpartmon of the connh,.wimrc
constructed,
Fonn GW-1 North Carotin M-W r ew of£nowtuncid and Natural Resources-Division of U'atct ReSolrom Revised.AuguS N)13
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