GW1-2022-04195_Well Construction - GW1_20220419

WELL CONSTRUCTION RECORD For oaten!Use OM-Y:
'fhb form cm be asod forsingkor m0ple%vUs
1.Well Contractor Information:
td.ii ATIt-T>:3N Fs
Brian Swing FROM 70 0MCHIP110N
k1`011 Consractnr Name RECEIVED
4240-8
NCWc1lCo=c1orCcriificationNumber 1S tl1Et2CtlSfi7Cr,fat nriibi ascifnrR Olt-WEit ria`"EkaQte', � 'ram t,
APR I'9 2022 FROttt To DIAMETER, THICKNF-n MA7UsTAL
SAEDACCO Inc 0 (L 6 It 2" tn. SCH-40 PVC
cotilF,my Norm 36 JNNE4i:CASI R` eothlfiN�`�lut�`d�dii '_t
FROM TO I DUUMFTER. Tt11C'IMS5 MAIERLALL
2.Well C,'onstrtTctiOn 1�crmit#; R. to �.
list 41 apliffrable well permh!s'O .Comm v.stwp,Vnrdaarr,if fem'art etit.) ft. fL 4L
3.Wdl Use(ckd;wdl ose): 77>S(RUN .:
� n oP
Water supply Well: FROM TO nrAMIKIr:rt st.OxsME. TrrX*1CFW MAIRI AT,
DAgricultuTat clmunidpavpublic 6 ft, 21 R, 2" tb O10 SCH-40 PVC
CGeothetmal(HeatinglCooling Supply) DResidential Water Supply(single)
a lridustrial/Commercial ❑Residential Water Supply(sbared) 18,;GROU1'.
FROM I To MATERLiL "UPLACUMM M MGD af;AMOUNT
Olrri tian 0 R. 3 IL PORTLAND POURED
Nor-Water Supply Well:
tL fL
mmanitorin
Injection Well: tt. rL
❑AgnFferftechargd ClfrolmndwaterRcmcdiation 10.AN61L�(tA
FROM. Tt7 faTrris ri, KMTN ,t �r t rtr u
❑AouiferStomge and ltecovCV ❑Salinity Barrier 4 R. 21 rL FILTER sAND # 2
❑Arivikr`fcst ❑Stomm-Iter ominage
R. ft.
OExperimcnial Ticchnology ❑$ubsidcnse Cpvtrol
❑Geothetnnal(Closed Loop) ❑Tracer Flaoat TO D�scRTFTto oobrserrm�rn x+nrri�crr n a as
❑Geaothenual eatir 1Cooti eReturn) 130dier(c4q4ainu3nder#21Remarks) o tL 5 ft. FILL iSILTY SAND
5 fL 10 ft. SILTY SAND
4.Date Well(s)Completed. 3-17-22 Weglm#Mw-03
10 ft. 21 (L SILTY SAND CLAY MOIST TO WET PWR
$y,We Lneatkin: �. ft.
Former Countryside Cleaners
Fac11h)o0=r None Fact1hy M9(fapplicnblc)
3007 Zeus St., Charlotte, NC, 28212 rt f4
P1q-iiial.AdIrcss City.and Zip 31. ER1ARtC$L: a
Mecklenburg BENTONITE SEAL 3 TO 41
Cnnuh PArCCt Ip nllocalion N0,(t`ttr')
Sb.i.atitude and I.nngitudc in degrccshnnirnmteAccoinds or decimal dcgrew. 22.Certification:
(ifucli roctdiaac hloorigis odlycktil)
N W E-riam .,Ew—Ingl®® 3/29/2022
Sigazore ofCertgkd Well Conrmetor Dare
6.Is(are)the_well(s}: oPermaneat or Memporary 11c.rbnfng Wt farrm 1 hereby rerly char dw wrf4r)vans(Werri[gwunreled in aecorddnce
ivhh 15A MCAG 02C,0100 or)5A KCAe 0.0:0200 Well Comsrer edmi Sron4ards and rhaa a
7.h this a repair to an ttisting well: Mft or ENo copy ofdih record dims Non pnn,1drd to she,arfd mvmrr,
d/Afs a o rtp4r.fill ow kmairw wellear n(Mon Arfrarrar yka mad rwfabt the wrwe of dtr
repair knder 621 remanU seofimv arm Air back of rhfs fnrnL 23.Site diagram or additional will details:
You may use the back of this page to provide additional well site details or well
S.Number of Wells constructed: 1 construction details. You may also alfaeb addition!pages if necessary.
For amir4pk 1j rkurax erei-wrascr rag aJr avlds ONLY word rdlr wMe conA alon,}4wAYw7
mbmdte"fo M SC1RNITUALINSTUCTIONS
9.Total well depth below land surface: 21 (ft.l 24a. For Alt Will Submit. Kris forat within 30 days of completion of well
Foram h0ple toofts fiat orli miff Rani;(a rarr{pre-3@21kf'and tw) eonstnration to the following,
10.Static rater level below top of tasiur. (n,} Division of Water R"ou rcm Lnformation Pracessing Unit,
1/s4rarrrtei rl it strove cdef ag,aLtr + 1617 Mail Service Center,Raleigh,NC 2760.1617
11.13oreholc diameter-8,25 S. (in,) 24b.Frrr 111fa DTt W, g ONLY: in addition to sending the form to the address in
24a above. also svbnut a copy of this forth within 30 days of completion of Bell
12.Well construction method. BORED consi etiotr to the followiing'
(i.e.sooger.ratary.cable diaeri push etc.)
Division of Water Remrce�Underground Injection ContrTil Program,
FOR WATER SUPPLY WELLS ONLY. 1636 MaR Service Cel ler,Raleigh,XC 276"4636
13a.Yield(gpm) Method of test: 24c.For Water SPUIX&lnlectiim itictRa:
Also submit one cop} of this filfnt Mtbin 30 days of completion of
1.3h.Disinfeeiimin.trin Amount:, wcli consinrction to the county l6fth department of the county where
constructed,
FormG1V4 i�bRhCam1'u�aD. relnacnno(£mimmunn8�NnnualResotaecs-Diti9sbnofRSnerR�otrGEa Rc%1scdAtCu5t2013