GW1-2022-06957_Well Construction - GW1_20220722

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WELL CONSTRUCTION RECORD
This form can be used for single w rnultipk ueclls For h9crtinl Use ONLY.
1.Wetl Cnntmetor Information:
:2JWet?I?R>ZONFS '
Stefan Smith FROM TO I DKICHIP1110N
%M01CorAlractorName 19.39R. 25 ft. Groundwater
3576 ft. fL
NC.WcllContmcrorCcnifrcali6niNumbir tS.`OUTER.CASiNG(toi mutil��tJAiefls'ORLiNER(if.-a [tcaDk:
MOsr TO DTAlt1ETEai TlrtrKNEss MATERTAL
SAEDACCO Inc 0 ft. 15 ft 1 2" I jin, SCH-40 PVC
Conyr;ut?11'atiw 36:INNERCASINGOR-TUBING- 'ioi rmat'ciosedaoo o;-
FROM- TO DMAIETER. ECKNESS, MATERIAL
2.Wc(l Construction Permit#; ttTM0301210; 70003022 R. fh lu
List ail apyxmbf,tscllpra wts(uz Colaim Stone,lroriarwr,1/.yre'dca trr..)
R«. ft. in
3,Wclt Ilse(chccicwdll uscl: t7:SCRlEN:
Water Supply Well: FROM, TO DrAMFITHi SLOTStn, 'TInCKNr s I AIATFRtAL
Ingticttltitrai ONfunicipat'Pubjic 15 R. 25 R. 2" in 010 SCH-40 PVC
Meothernut(Healingt'Cooling Supply) ®Residential Matey Supply(single) Ft. fL. irr:
©htdtlstriallConuttercial Mesidentiat.WaterSu M1 GROUT.
PPh'(shared) FROM TO MATERLt1 MPLACENIENT AWMOD S AMOUNT
l7lrii" flan 0 ft. 10 fA Portland Cerftent Tremie
Non-Water Supply Weli: R«
®INonitoring 1311cco-cry ft. ft
Injection Welt:
®Agnifcr9ccbaq0 06vat tidymterRcmcdiation =19 SANb1GRAVELVACK(if t mlitdhtLf= _
HOaf To ltATKEU.At: hs1PL,tg-,%n,NTMr:Trton
t]tlgnifer-Storage and Rtcorci}' AS linity Qariicr 13 R. 25 ft. Sand #2 Pour
❑Ai(nefer lest• QSJoaimtraterbnr na'c
R. ft.
MV.crimcuh,I' cchnotogy l7Subsidcncc Control
-26?DRILLI NG'.I:OG latt9ch addhitnial glicetd if brccsmry
OGeodiemmal(Closed Loop) EITracer r ROIT TO D�seRrPrtaN cubr.6aMnc t wR'nKktr 'n 3mHt 1
e
❑Geatltentral(Ilea(inglCoo[Iug Return}. ❑Otlter(plain under 921 Remarks) ft. 0.75 ft, Concr
sl ;, te
0.75 fL 3.5 ft. Clay j
1.Date Well(s)CablPleled: 6-9-2022 Well11Dt1MW-3 3.5 ft. 25 fL Silt i 4
- •
54,Well Location: _iL ft. w
i,
NRP Holdings, LLC N/A ft. R« WADf1Ma On ProceV
FacflityjUivacrNmee Fact7ity ON(ifappiicablc)
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3934 Raleigh St., Charlotte, NC, 28206
I'
Physical rCddrass.City.and Zip ;2t:HEntARi(,S
Mecklenburg 09107202 3 foot bentonite seal from 10 to 13 feet
Count), P=0 ldkniii(tQjlion No,(PIN)
56«I:atitude and-Lr ngttudc in dcgrcc0ninutcsl5ccands or dee mal(li g,Lnt : 22.Certitit:ation:
(if t rll t'teld,o k'..1; loyg is str(Gckrtt?
35.150671553 N 80.474941364 W q i 7/l/2022
Sil af.ded Well Contractor;' Date
6.I9(arC)lhC tseU(y): %IPCrrtlBbent or aTCmporatg' at air ihi3 arm.1 here-by ierr! fhar flu ue!!r1 tsrts(mule}(xmiruererl pit&%TgrJm.cr
�3.S h f 3' ' f}' .
u'irh 1�1 aYG1C OTC.A1GY1 or!SA A'Cr4G t7tC,p20n 1Fi1!Cnnsti;tcdott SWnriards alai rlxri a
7.(stkbi,a vpairtoanc-M-ttingwell. ®Ves or MNo 'coy oftlikFecoigilias•ltrenpmr4kdiiiil0irllmmer,
if rhts'&.a repair,fill wr ku1;n?i weil&Tannwdom btfamwilmi ivul eAPIa!n rile rowane of the
rrlrcir=dcr#21 remcrlts arriiup ar un Me bra•L•oft"-form 23:Site dhigrdw-or additiouatwell details:
You tuay use the back of this page.to pto%i&additional well site details or well
8.Ntrtnberof wells constructed: 1 constmetiou details; You way also attach a"tionaipages if ttec:essary.
For maldple h:j a"ior am-}roarer-snp[dy wells ONLY Wrh rho,same corrstnretlwr,yoit crap
saprttitate forii. SO61 ILML INSTUCPIONS
0.Total welt depth hetow land surface 25 ((1,) 24a. Far All Wellw Submit this farm within 30 days of completion of welt
Foe;traMpleiMisli,tour:.reprltrlfdoermrleram�le-3@2M,did 2@M91, construction to the.foitoningr;
10.Static eater level below top of easiDW 19.39 (11„) Division of Water Re,'iourcev,InfurmatianProcessinx Unit,
1/tvcater loge!is cbme casing;due"+" 1617 hiail Sert'ice heater,Ralri r,vC 21699-1617
It.Borehole diameter:8.25^ (in.) 24b.Fnr Infection Welly ONLY: �n addition to sending the font to the address in
24a aWe.also submit.a copy of this farm within 30 days of completion of u0i
12.Well construction method:HSA construction to the following: If
(i c.augr-rotary:cable ush direei petc:} Division of water Resaurees,Undergrotnrd Injection Control rro;ram,
FOR WATER SUPPLY ONLY: 1636 Mail Service(Center,Raleig h,NC 27699.1636
13ar,ti cod(gpm) R'Icthod of teat: 24ca For Watcr Supply dt Iniectfo I Wells:
Also submit one copy of this flint within 30 daysofcompletionof
13h.Disinfection type: Amount•_ well construction to the county 611th depaument of the cormh,where
contoured.
Form011-1. Noah Caimllm Dcpannaia of Em'ironmcnl and Natural Resawres-Division of Water Resautm, Revised August 2u13