GW1-2022-06958_Well Construction - GW1_20220722

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WELL CONSTRUCTION'RECORD FailatcrualuscONLY:
This farm can be used for single or.multiplc nvclls
1.Well Contractor lnfortuation:
f-05N'd2ER ZONn-
Stefan Smith FROM TO DF ciffipT(ON
U101 Com.maoi- am, 21.93ft. 30 ft. Groundwater
3576 fL fL
NC\VcllCatthactarCcrtif[cmionNttttbcr "IS.00TERCtCSiNG foriariflicasell cFls''ORLiNER(iia"'lkableft
FROM TO DrNtET6Rl TSIIGI+Aa65S AIATEMAL
SAEDACCO Inc 0 tta 1 20 ft 2" I hp, I SCH-40 I PVC
CoaV.-uty Naatc 16:INNER.CASiNC OR TUBING; iroibetml d e5amd400
FROM TO DLLNETER: THICK,AIESS MATERIAL
:.Well Constrtletinn Pt trait :WM0301210; 70003022 O, ft; 11L
1.isrtrllnpyilica�leux�llpeimilsfir..Cnunry;.Stet:r.,Ynria�r Infsd[alefr,.J '
3.Wd1.U5c(Ckecl:well usc): f7 SCREEN
Water Supply Welft FROM. ' TO RtAM1IETRIt SLOTSI7.F Tiff.0 Nti+;S MATERIAL
ClAgni,ulmrat CI14fuoieipalFPtttllic 20 it, 36 R. 2" in' .610 SCH-40 PVC
BGeoUlemnl(Heatingl'Cooting Suppty) ®Residetttia[Water Supply'(single) fL ft ioi•
ObidusdialfConmicicial ®Residential Niter Supply.(shamd)
-
FROM To ATAT'ERrAL EMPLACEMENT AMMOD&AA101TVT
01rdoation 0 f. 15 ft Portland Cetent Tremie
Non:Witter Supply Well:
tt. ft,
®Monitowing 17Rccosrt}
Injection%Vellc
MAnuiferRc6argC Mrmuntivnicr Remcd(ation 19%SA.NDIGRAVEI PACK'(if
A�ijnifcr StorgcanRcc6Vcq izar PROSt O 1tArpRIAI:
hAlPt�t(:t;Afl-NTMETPtOf1
18 R. 30 ft. Sand #2 Pour
❑AquifceTcst i7Slortnm:ltcrQri ago ft. ft;
EIENperimen(aiTochnotogy. ❑Subsidence Cotitroh -2n DRILEmGILOG7nttach addiiiomhl slieetf ikwmsaryl
OGeotlten=d(Closed loop) ❑Tracer FROM TU DESCRIMON(Monh:intaec4 wa,'nickO ti wadr.)
Ot3eotltenna!(HeaGnFJCoollne Retum}. 130ther(plain under#21.Remaiks) U ff. 0.5 to Gravel
0.5 fL. 3.5 (t. Clay
4.Date.�Veu(s)Conipleted: 6-8-2022 ID#MW-5 3.5 ft. 30 fL .Silt i '
54.Well Location: ff. k4 i
NRP Holdings, LLC N/A
FactlitpOwNr Name Faculty IDN eifappli able)
3934 Raleigh St., Charlotte, NC, .28206 ft. fR mes"Rig r*
I
Pltysica .mmress,City.and Zip ;2t,'t1EM1lARKS' '
Mecklenburg. 09107202 3 foot bentonite seal from 15 to 18 feet
County >.'rcel ldcutlffcmtloallo,(PIN)
fib.I,.�titudc and Roil itbdc in t<eglte5hninutesl3caintls nr decim tl(tcf t a5: 22.Certification.
(Ifti;Ln rota:��:L'ttiloas is sitrriciCat)
35.150771285 N 80.474823246 W 7/l/2022
Sigalt af.Ce: Icd{VcllCatttrnetar Date
6.Is(are)thewell(s): MPLnitanent or- OTemporary ei roil lkh,arm,1 hefeb cerli 4 flat!the rell sl xis•(brie!mrsfrmewd ur,atirorrlmmce B3' S 8 f� Y !.' �'.
pith RM NGtC 02C.Olt['?or 15A NOW Ok.0364 Well Construerlcir Sramfards avid rhtir a
7.L,this a rc' ir" an c�h t' ell.- Ewes or ENn. rotiy bfdt r ircair!l+i:s berr,nrnrirlitl ru i1H sir(l mwter.
IJrhla:&a rir}�tir,�ll air krouzi[`veld corurnrerlon hrfofourrl ar mu!vaiilabr rba tartar¢of die
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repair am r B21 remarkv xecfiari of on the back of rhir form. 23.Site dia rath or additional well details-
You May-Ilse Ili¢back of this page to provide additional-well site details or bell
S.Numberof wells constructed: 1 cousiruction details. Iran ina}aisa atlachud(litioDat pab�es if t►ecessarv.
For;1fJ11dP.,(adidecrinrtororal-purersapp(wa'rlfs ONLY Iddl(he sgmecirrrsrrrrrliorr,youu.era
sabmlruncfomi. SUBMITTALiNCTITCTiONS
9.Tota well depth below land surface•. 30 (f►,) 24a. Ear Au Wells: Subinit this fonn within 30 days of completion of inelt
FoP rrriilriple ivellelrsr a.11defuhs 1fdl,(,'erem(em ipfe-3@200'arul20 clan[) con5lmation to cite foiloRino
Ia.Static water level below top of casing: 21.93 (D,) Division of 'sttcr Resaurc ,InfotmatiamPmcessin�Unit,
if wamt legel Is above,aaslng,rue^+" 160 hiaEt Sm ice tic ter;R leigh,NC 27WJ-1617
11.Borehole diameter:8.25" (in.) 2411.l nt Gt - . on Wella.ONLYi in addition to sending the fonn.to like address in..
24a abo\'e,also subtuit a copy of this,fonn within 30 timIs of cotnpjOion of%vail
12.Well constmetiou method:HSA coustmetion to the following'
(i.e.auger ratmy,cable,dixcct-pimb.ctc:y
Division of Water Resources.Underground Ialeciian Control Program,
FOR�YATER SUPPLY WELLS ONLY- 1636 Mail Se"Icc tenter,Raleigh,NC 27699-1636
13a,field(g#m) kcibod of test: 24c,For Water SuDRIr&Iniectr4a Wells:
Also subnAt one copy of this faint within 30.daysofeotupletionof
13h.Disinfection e• Amaunt• well consinirtion to the cotmn•ticalth department of the counh•.witcm
�r +II
. eonsmlcted.
Fenn GAT-t NonhC=Rm Depanrt>m of Eavirommitt arrd.TatmW Rcmtuces-Divislon of Wate Resouto Rievised august 2013