GW1-2022-03366_Well Construction - GW1_20220314

WELL CONSTRUCTION RECORD For I1t:Cnktl Use ONLY:
This form can be owd rot single or nmhiple svclls
1.WellGnttractor information:
14.%VATER ZONES'
Stefan Smith FROM To DFSCRIPIION
Well Contrrctot Nana
3576A
NC Well Coorac)or Certification Number 15.OMRCACtNG formuhi•cascdee0s'ORLIN- it_i IkaAk
IRON TO ntANtF.TER 11ttCKNESS MATERIAL
SAEDACCO Inc 0 ft. 8 ft. 2 in. 1 40 PVC
(:augrut\'NSrlrc 16.1NNER CASING ORTUBING(eotberruitclowd„ •Nnor)''
FROM_ TO DLAMETER THICKNESS MATERIAL
2.♦ ell Constivetion Permit#: fi. n. in•
lest all alyrlirable well pr+mils(Le.County:.St cte..lirrianre.,lryt Cn rir.)
fr, ft. in.
3.Well Use(cheer:well use): 17.SCREEN
Water Supply Mlell: FROM TO 1111ANIM14 $1ATSIM TIIICKSMSS I MATERIAL.
Oftficultural i3MunicipaMtblic 8 ff. 23 IT. 2 in. olo 40 PVC
OGeothemral(1-1cming.'Cooling Supply) 171tesidential Water Supph•(single) fL it. run'
01ndustriatlConmlcrcial 13Rtsidcniial Water Supph•(shared) 18 GROUT
FRONT TO MATERIAL I £MPL+CEMCN'T\IUMOD&AMOUNT
❑Ink ation 0 ft. 4 ft. Portland/benl;neAte
r
Non-Water Supply Well: A. A.
MMonitoring ORccovcry
Injection Well:
[]Aquifer Recharge 13Groundn rtcr RCnrcdiatipn 19.SANbIGIt t VEL PAC.1C'(d 'rlkatile
FROM TO MAURrAL F.MPI+CUMENT MITHOD
❑Aquifer 5tortgc and Recovery ❑Salinity•Ramer 6
❑Agr A. 24 ff. Sand 2ifcrTcst ❑StormwitcrDrrinagc A. ft.
❑E Vcrimcntal Technology ❑Subsideucc Conlrol
"20:',DRI1,1dKG.LOG 7attach additional sMNs ifnccec.an' '`
OlGeothemral(Closed Loop) OTracet FRONT To orsCRIPTION Rotor.harHncc+,*.Ivnwk ly1w.plain Ste.Nc.)
DGeviliemral(Heatin toohine Retook) ❑Outer(explain under#21 Remarks) 0 ft. 24 ft. Sandy silt
ft. (I.
4.Date Well(%)Completed: 2-22-2022 Wd1ID#Mw48S ft. ft.
Sa.Well t.ucatlon: it. 1 ft.
Camp North n. ft.
Faciliiy,40+vncrNamc FacilhyID901'appli:abic) A.
1824 Statesville Avenue Charlotte, NC 28206 Meckle, ft• fr. /1l(
Charlotte, NC, 28206 Phi s"ral Address.City.and Zip 21,REMARKS "
2 foot bentonite seal from 4.to 61
fanrsN' Parcel Id;nsiftcaliouN(r.(PIN)
Sh.Latitude and Longitude in degnccs/minutes1seconds or decimal degrrcc: 21.Certification:
(ifuen Geld,one latfloq is sunicwml)
35.248288 1� 80.833053 �fr' _ _ _ 2/27/2022�wr�
�_Jidliicd 3�'cll Con[n.tor.,.,. ,.. . _ _.M. Date
6.Ls(are)the well(s): :51Per nanent or OTemporar r
M srgniny this ftlm,l hrrrlrr e'eHrfv that dien'rll{.+'I uvrs{purr)cvrrl3•uurrrd io m•Cardtmcr
i6ift U4 NCAC 02C.01M err I M A101C o2C,02'00 Well ll Con;mv eikii Srmrdaids tied that a
7.Is this a repair to an eucisting+vdl: OVes or ON) a ryry rf this rernni hus lti rn pnn•ided ter lbr+n'll ruiner.
if ihls i.r a relmir,•ill two:L'rttrnit n•rll r04sinirliew hrfomiadonand explain die itarure of der
reiwir tnrilrrP21 rmarks ser imr or im der brn•k of dih farm. 23.Site diagram or additional well details:
You may use tile,back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pab*es if rM.tiessar)'.
For middple iofeedon or arvt-+rarer suplric+eeih OA9,i''n-1rh die taunt cortstrudlon,i'aa Can
.+almdr one faun. $SLl1111TTAL]�',ST I�TIQNy
9.Total well depth below land srrr face 23 (ft.) 24a. For All Weil%: Subnut this fonn within 30 days of completion of well
For widilple wells list till depths Ifdifterent tea-mnple-3@2W',ovi 2eIm) construction to the foltrn+inG;
10.Static water level below top of casing: VL) Division of Water Resources,Information Processing Unit,
If ntiiiet level h above rasing,tits•"i" 1617 Mail Service C entcr.Raleigh,NC 27699-1617
11.Borehole diameter:8 (in) 24b.Far fiticcdon 3&:r11s ONLY: in addition to sending the form to drraddress in
24a above. also subunit a copy of this form within 30 da)'s of completion of well
12.Well construction method: HSA Construction to the following:
(i.e.auger.rosary,cable,direct pusk etc.)
Division of WatcrRcsounrs,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 276994636
13a.]add(gpm) Method of test 24c.For Water Supply&Injection Welts:
Also submit or* copy of this form within 30 days of completion of
13h.Disinfcyxiun h'pc .o_ Amount:_ well construction to the county health department of the counh'when:
constructed.
Forn GW-1 North Catalina 0.-pnns:ucof Encirowrici t and Narita]Resources-Division of Water Resowces Revised AuguST N13