GW1-2022-06956_Well Construction - GW1_20220722

WELL CONSTRUCIION RECORD For h9crnal Use ONLY:
This forin can be used ray single or rru ldyk iwils +
1.W&I.Contrtctor Information:
la:tvATERZONES i
Stefan Smith FROM 'M I nF-impTit}N
R1e11Cnn4ralgorName 21.87R, 31 ft. Groundwiter
I 1
3576 ft. ft
NCWellCommelarCenif=tionNuwhir i15.CUTEItCASiNG(rnriuutlt-cased',6igs OR-LiNER(tfa"ficabk.
FRONT TO Dt'"Su n TTICKNESS MATERTAL
SAEDACCO Inc 0 tit 21 ft 1 2" I !1n, SCH-40 PVC
Cnmgrul}Nank MJNN"F 'CASING OR MiNalkedcherihat clasudaao
FRONT 170 1 DUMETER I THICKNESS INi.4TERIAL
2.Well Construction Per'Rlit Rp WM0301210; 70003022 R. tit,
lisr tdl rpy,lisnbde ucN peimits(ca:Comtht Slue,l�Griorrte.Ti}'BCDeat efc.1
ft, ft. ter
3.Wc1L Use(chccic well usc): t7:SCRt 1 N
Water Supli y Well- FRONT TO DIANFFT19R SrOTSIM TIRCr MNS MATERIAL,
C1Aglicillhtral CIl4[unieipalll'u�)lic 21 R. 31 R. 21, in' .t)10 SCH-40 PVC
Meodterrnal(HeatinglCooliog Supply) DResideutial Water Supply(single) tit ft.
01ndustriaVContnicicial Mcsidcutial Water Supply(shared) ta.GROIil
FROM TO E1tPLAMFENTMEMOD&XITOUNT
❑uri rt;n,1 fa tit,
Non:Water Supply Well:
tit. Q.
®Monitoring 011ccotrty
injecllon Wr11: tt. rt
0AttniferRccbarge l7Gtouridwalcr1(cntcdiation :19is."DIGitAVELPACx61` ,11iclbtel-
-Frtolr 10 1 NL1'rltltrA1, RAM%Cf VENTM r11011
QAilnifcr-Storage and Rccovcry QSalinity Bather 19 ft, 31 ft. Sand ii2 Pour
❑AgnifcrTcst 17510rm}tatcr6;t n7gq
C71 Npetimcntal Twhnotogy 17Srtb5idcncc Coldml ;20;:DR1LL1tiG'LOG raltxd addiliorial OM9 if weessan•1
134 twihennal(ClusedLoop) OTracer FRONT TO DsscRrrrl�x tuar.nutducei 511a\mekft :- 'n we.nr.1
❑Geothenllal(Heiting-Cooling Return)- ❑O11ter(explain under 921 Retua&LI 0 ft. 0.5 ft, Gravel
0.5 ft.. 5 f. Clayey Silt
4.Date Well(s)Camplcled: 6-8-2022 Rrclt 1Df9TMW-6 5 f4. 31 tie Silt
Sa,Well Lticatinrr: ft ft v
NRP'Holdings, LLC N/A ft. tit
FaciJNyj0ivwrNamc Facilily1D#dfapp1Wb1c) tit, ff. ' RPC�=
3934 Raleigh St., Charlotte, NC, 28206 ft. ft.
Fksicul,addicss_City,ttnd Zip IL REMARKS'
M1IARK5'
Mecklenburg 09107202 3 foot bentonite seal from 16. to 19 feet
county Nrcel ldvilif%cjlion No,(PIMV
Sb.i.�atitutde aril Longitude in degreeslndnutcs1kconds or decimal dcgrm' .. 22.Cettificatit►a:
(Ifvell 004'Ptn I(t(lltSu,la Snfnck ld)
35.150739493 N 80.474709712 W _ �j 7/1/2022
Sign�t�Cc' Jiad Well Contractor hate
6.h(are).the well(N): oPen nanent or ZTemporary By wigging lhir fonts,11ereby rerlify ri:i r e irell(.x)was ftSi r j[Ylw1rurieI hr.anvordldncL
n'irh MA KOW 02C AIM or 15A IVCAC 02C.02M Well Constmeriott Searxfarrls rend 11xi1 a
7.Lsth;sa repair to an.Existing well: E]Ves or MNo rnpra/rfisrrroniliastnaul,souls&r1ra.rfr'rn:llmener.
if rb1S IS D repair.till fMf An'alt7f It'l'll C}RfASrr,eC110a brfOl7Ar111tNI aril t:rplai,r the earn"of rAc
repair meder P21 arinrerdr arclian or an the back-of this fors. 23.Site dritgraut or additional well detAU:
You May use di'e back of this pag�to pro%ade additional well site details or well
8.Number of wells coustmeted: 1 coustmction deleils. You inav also attach additional pages if accessary.
For malrlple Ikker1D11 or n a-t-yaterApply It'r11s ONLY u'ddi rhea some colrstrai'ffon you cart .
.rrlbnth eue fofrn. SCIDIITITTAL INSAICTIONS
9.Total well depth below-land surf ce. 31 ((1p,) 24a.- Far All Wells: Subnlil ibis faun �ilhin 30 days of completion of}welt
For,rexidple iveldslisf rilVeprhs IfdWeF-c,tt(eraot),lc-3@200'aixl 2@ 100'Y cOnStntctipn to the following-, ,
10.Static water level below top of casing.- 21.87 (D,) D;}isian of NYater RcsUUFCe s,tniormatianPrucessio,Unit,
If nailer level lr obotv.'cndlig,am"}„ 1617 Mail Set-vice Ceuter,Ralciah,NC 27699-16 t7
• I �
It,Borehole diameter:8.2511 (in) tab.Fnr infecNnrZ,�Vp�Fjq ONLY.- in addition to sending the fomt to the address in
24dabove,also submit a copy of this fonu within 30 days of completion of hill
t2.Welt construction method: HSA MlStnldir}u to the folloMfle:
(i.e.mtgcr.rotary,cablc,direct guslx ctc.)
DIvislou of Water Resources.Underground Iujection Control['rograut,
FOR WATER SUPPLY WELLS ONLY: 1636 Mill Service Ceinfer,Raleigh,NC 27699.1636
13:t,Vicki(gtrm) \$cihod of test: Ito For Water Suer in_v&iniceti on Nyells:
Mso sub"t Wife copy of this fiiW within,30 days of completion of
13h.Disinfection Amount avil•consinlction to the connl,liCalth department of the county where
type., ill
corwTucted.
FawnGtV,l honhCarohmMparimcntofEmirotancm and Natural Resources-Divisionof Al.I iRewvrcm RevisedAugust2v13