GW1-2022-04197_Well Construction - GW1_20220419

WELL CONSTRUCTION RECORD Fertrarnol Use ONLY:
This.form can be aged for singk or nndlipk,wells
1.Well Contractorloformation: D P C�i
E I V D F'R.14., TER 2OTl1 S
Brian Ewing _ RM TR p�t;:Rtr*I9t3N
Wdt Co men Narm
4240-B
A P R l 9 .2022
NC Well CormmdorCcrlifizatioaNumber 15 OUTE1tC215tNG oTinrvttleifset'k n 'Oti .11�FR its Flciitik: ,',< a;
100rm wn Proom-ingUrA FROM TO PrAm-mit T"ICKMES5 I AIATLRTAL
SAEDACCO Inc mejoilsoo 0 (L 7 fG 2" in. SCH-40 PVC
C lq,ml Name 16.`7T1 R G,LS'ING'OR`T BIhTG i iuk da l
FROM TO oVOUTER. THICKNESS MATERIAL
2,Well Construction Perrnit M. ft. It,
list all applir(Mr wdi pemrits fix.Cnann.Slate,-Varla-r.fPir an rrc)
(1.
3.Wd l Use(tom.well use),.
Water Supply Well: FROM TO nrAMPTFIt STA)TSIM "ITMNIZ'S I MATERIAL
DAgricuitural 0Mnnitipallmlic 7 ft, 22 M 2" IR• .010 SCH-40 PVC
®Geotkfml(Heatingtooling Supply") DResidentiat Water Snppb,(single) fG ft.
OlodustriaMominercial pR F
esidential Water Stipply(ftTed) FR.GRo[}T:ROM TO MA't'l3RltU
t, EMPLACEMENT MSitiOA&,'UH'OQtVT'
01di lion 0 ft. 3 ft. PORTLAND POURED
Non-Water Supply Well:
Immunhorin DRcco-. r�
Tnject(on Well: (L (G_
0Agniferitcch3rge adroundn-atcrRcmediation 191.SANI)IGRAf trlA[ V,' R%bk "-
Ci egnifcrS10rage and R=QVV p pSalinity Rtttricr efts?*t m nta kcat. rMw aCtyt'vT_ I Art n
5 ft, 22 ft. FILTER SAND # 2
❑Agnifcr Tcst [3&6mm'atcr DrunaRc
01 aPcrirrtcnta173xhn(ringy OSTrITsiitcrrct Control =o,11RILLt.IKC'WG"(eiiacli�iAditiam l ztMefsif ncccssiira
❑Geotlmnial(Closed Loop) ❑Tracer .FROM TO PESCRIma colar.hardlitn vr.}knratt gypt,P*ft*,atkel
❑Geotltennal eatit r oal Return) 00tler( in under 0.21 Retuarks) 0 fL 5 fL FILL SILTY SAND
5 rL 10 ft SILTY SAND
#.Pate Wiet(s)Conlple(ed: 3-18-22 WCHITtfr<MN-OS 10 fG 22 fG SILTY SAND CLAY MOIST TO NET PNR
Sa;'1"ell Location: (L rG
Former Countryside Cleaners (L ft
Fed#•)0woerNam Facility Wo elf upplicdblej
ft. fr,
3007 Zeus St., Charlotte, NC, 28212 fG
Mecklenburg BENTONITE SEAL 3 TO 5-
CorrW Prunes lrtceulrmlion 140,(PINS)
$b.Latitude and Longitude in degrecslm noteslsetonds or decimal dam: al,Certification:
(1twoll COCK 4ux tt ongis*idtieierrt)
N W Br . n w— ng. 3,29,2022
Signauru ofCert'rlred Well C6imtor Dare
6.Is(are)the weli(s): rMPernranent or oTemporary 11.,signing whir farm,P hereby cetnfp i'bau Mr mefl(s)vVj(Wire)cmwnremd ire tx'cardante
with IJA NCAC 02C.0100 or 154 NCAC 02C.0200 Rill Cora mcdon SmWards and Alai a
7.Is this a repair to an esisung well: OYcs or MNo ropy of(fih sword lag been Frtrridcd err rf r.curl►aunrr,
l,(rhis ix a arperlr,fall.ayA firtvuxrr>l�ttl t�v+rmtc�ra(rq'arrvrnAlca.nxl r.�P�i�r Atrc nrrvrc r3frlc
Arlen%r rrimtar6`2P nsmanCe iiora arrxa flit lrx•,C o f LMs/urm. 23.Site diagram or additional v011 details:
You Bray use thi back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction delails. You may also atiachaddidoral pages if tlecessary.
For ma W#e ttr*rkwi rx mm—it Ara r•ssgpJr•iMh 04 LV 10A the-mme tonstrtrclkar,WW em
m6ndr owe farm. SUBMITTAL INCT T `Pltl S
9.Total well depth below land surfaec 22 (fr.) 24a. Far All Well., Submit this forha within'30 drips,of co"tetion of well
For m1fi le wells hsr afhfe nts ff dWrim fcram**-MAT aml 2@ 1117'1 consOuctior1 to(k following;
i0.Static water level below toll of castng: __ (Iy.) Division of Water R6ou rtm tPltnrnlatiott Processing Unit,
if miler Wd is above rd XNR,use"+' 1617 Mail Service Ufticr,Raleigh,NC 2760114617
i
It.$or thole diameter:8.25" (ia) 24b.For 191a4.11$ .h ONLY: in addition to sending the foml to the address in
24aabove. also Wbmit a copy pf this form within 30 days of completion of melt
12.Rich construction Inarbod: BORED construction to fire follocvirrg_
(i.e.super.n9aq•,gable direct pusk etc.)
Division of Water ResaTu recce Underground TnJectlon Control Ptograim,
FOR WATER SUPPLY WELLS ONLY: 1636 Mad Ser .icetenter.Raleigh,NYC 27499.1636
11%Yield(gpm) Method of test 24e.For Water Supply&Injection Wells:
Also submit one cop), of this fonn rsithin 30 daps of completion of
13b.bisirrfrtitian,tip� Amount: well construction to the cvttnty ltcahtt dcpartmerrt of tie catrnh.whew
commictcd.
i
Form G1V-1 harsh Carelim t?woueni of Em•im mnu aid.larasl Resomes-Division of%lcr ReSotrom Rc%,iwd Agra 201.1