GW1-2022-03365_Well Construction - GW1_20220314

WELL CONST UCIJON RECORD For Inrcnint Use ONL1':
This fonu can tic owd for single or muhipk calls'
1.Well Contractor information:
Stefan Smith FROM TO DFSCRIPTION
Wo-11 Contrn'uor Natm A. ft•
3576A
NC nfcll Cotnracfor Ceti ifical ion Nuniber 15.VUTER CASING ffoi:itiuhl-iasrid_iirRf 0R'LINER(1146 kahk"
FROM TO TIMMETER THICKNESS 1fATERtAA.
SAEDACCO Inc 0 ft. 69 it. 2 in. 40 PVC
(;:antirru�)Nantc z16.1NNER CASING OR 777BING ea fhermatlbceddonp'
FROM TO I DLAMFTER ITIfICIs\EEC MATERIAL
2.Well Construction Permit#: ft. ft•
Litt all applirable well pe—its(i.e.C,ounty.StTfe.Vnriatrrr.I48c6crt eir.)
ft. ft.
3.Well lisc(check well use): t7.;SCRti CN -..
Water Supply Well: FROaI I TO DIANIFTER SLOT5t7.i THICKNISS' I MATFRIAI.
OAgticultural 0municipalfPublic 69 ft. 79 f1. 2 in. 010 40 PVC
DGeothcmtal(liewing.tGooling Supply) OResidential Water Supph•(single) ft• ft.
0 hudustriallConumcrc-ial OResidential Water Supph(shared) 18.GROifTFROM I TO MATF,RUI. EMPLACEM"I'METHOD A AMOUNT
DIrri ition 0 ft. 64 ft. Portland/be'T—ike
?ton-Water Supply Well:
It. A.
bitifonitorinq ❑Rccorcry
injection Well: ft. A. I
•Aquifer Recharge 06roundnhtcr RcinWiation 14:SANDK:fL�1 EL PACK id tlkahlb
L`Rlidf M MATERIAL FMPI A("rtlr�T MPTHOl1
❑Aquifer Slor gc and Recovers- ❑Salinity Harricr 67 ft. 82 ft. Sand 2
DAgiiifcr TcV ❑Stour uatcr Dminagc
ft. rt.
❑EspcdmcnW Technology ❑Subsidence Control
20:DR AVG'LUG fattish atldil`itmal slreels3Gnceesstiry" ". 1
❑Geothennal(Closed Loop) ❑Ttacet FROM TO nF.S'CRIPTIO\tcohr.hprdnet,4,Vn�L ly n>we,/lc:t
❑GWthemfal flaeaungtCooline Return) 00flier tex lain under#21 Remarks) 0 ft. 47 ft. Sandy silt
47 ft. 80 ft. PWR
4.Date Well(s)Completed: 1-18-2022 WelllD#MW40T 80 h. 82 h• Rock
Sa.Well Location: ft. ft.
Camp North ft. ft.
Fac:iNi%Owner Nang Facilh 1Dk(if aWk-ibic) ft. ft.
1824 Statesville Avenue Charlotte, NC 28206 Meckle, ft. ft.
Charlotte, NC, 28206 PL)5ical Addmss�Ciro,and Zip 2t oil INARIG,S'
3 foot bentonite seal from 64 to 67,
(ortuty 1 attel iiktrlift=niunNo,(PiN) >
r,
Sh.lattitudc and I.onotude in degnxs/minuteslseconds nr decimal degrees: 22.Certification:
(ifcrell frcid,note Iaf7r)ttg is stdiicicul)
35.246540 N 80.833403 W _' 2/14/2022
Srgnsr of Cc aficd tVcu Canrn for Dafc
6.Is(are)the well( ): IPerrnanent or OTemporary tn,signing this fatm,.I herr)-r errtifr Ihry Me crr111.+)mws fmrir)rc emncied in tx'c'on mee
n•ilh!SA NC.iC 02C.01(k)sir IS,t A`CitC a'C.t,)2M Nell Cpnsrrarrian Srntkt(mix aril rlmt a
7.1s this a repair to an existing well: OyC5 fir 131sio copy offhk reran!ba,+Mra ploOffid mole slept former.
if tiffs is a,epwir fill eau t aot+w well rotas;turviaa btforr+470'on aad cs'plaitt rift•tut rare of rife
reluzir wrflrr#21 mnarkv smefim or tm the barA of Mix form.r. 23.Site diagram or additional well details:
You miry'use the back of this page to provide additional well site details or well
S.Number of welts constructed: construction detains: You may alsd attach additional pages if itecessan.
For multiple bilecrhm(H+tail-Wa:er aupp)c wells OJVl Y veirb fire some Conslruewon,cell Can
submit one form. SUBM11 A]• LNS,TUCTIONS_.
9.Total well depth below land surface. 79 (ft.) 24a. For All Wills: Subndt this form within 30 days of completion of swell
For mubiprle wells tict aft depths ifdifterew(exmraplr•3@2M'allot Zq MY) constnction to the following:
10.Static water level heloW top of easanS: (ft.) Division of Water Re3ources,Information Processing Unit,
If snider level is shove rwiag,use"+" 1617 Mail Service(.enter,Raleigh,NC 27699-16 17
11.Borehole di meter 6 (in.) 24b.For tnlcction We11s ONLY: hi addition to sending Ilic form to Ilte address in
24a above. also submit a copy of this tarot within 10 days of comµletion of Well
12.W'cll construction method: Sonic construction to the following:
l i e.auger.rota*,.cable.dimel pusk ctc-)
Division of Water Resources.Undcrgr`oond Injection Control Prngrant.
FOR WATER SU•PPLV WELLS ONLV: 1636 Mail Service Center.Raleigh. tC 27G99-163(i
13a Vidd(ftpm) Method of test 14c.For Water Sunlit)&Injection Wcllc:
Also submit one copy of this f(nn within 30 days of completion of
13h.DicinFectiontype: Amount- well construction to the county h n ealth depnment of the counts•.%%Here
constmctcd.
Fonn Gus'-I Nonh Catolilta Depannr:nt of Eta imiunew and Natural Resources-Uhision of Watci Resources Rcc•iccd August'-1)13