GW1-2022-06965_Well Construction - GW1_20220722

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WELL CONSTRUCTION RECORD Far Ttaarwl Use ONLY.
•ills Earn can be used for single or maltipk rsclis-
1.Well•Cantlactor Information.
'MAN
ATERLONFS` J, i
Stefan-Smith FItOb1 TO 10MCRUVON
%M01 CaniradorNam¢ 27.21R. 37 (t. Groundwater
3576 (L fL 1
NC Well ComractarCcrtifrcntion Nuunhef 115 OUTER CASING'(fbi^inull ea4ed�se11s'OR LiNER(it a'"lWablel,
FROM TO DrA1tF.TBR Torch MESSI MATENTAt
SAEDACCO Inc 0 fL 27 fL 2" I SCH-40 PVC
Carr�rtnv Namrr .16'INNFR CASING ORTUBING'I iaiheriivatelaced-loa'
FROM TO DFAMETER TII;Ct NEss MAIMkI.
2.Welt Cbnstrottiitn permit 4: WM0301210; 70003022 R._ ft, b�
l iu allcpp7icri6lc x'Npenafts(1_c.Cbun%`stu.'c,.Variamre,Jg4xdca efr.)
ft, ft. ire
3,WCA.[W(chccic Wdl asel. I7 S(1tl CN.
Water Supply Well: FROM TO DIAntUrR SLOTS;": THICKNESS MATRntar,
Mglicultuml 27 (i. 37 R. 2" in•• .010 SCH-40 PVC
ClGeolhenml(HeatinglCoaUDd Supply) ®Residential Water Supply(single) fL fL In
ModusliiallCoumicicial ®Residential 1Vater'SUPPb'(slhtied) 'I&GROUT.
FROM- To MATERFAL EMP[ACE,MM METHOD&AMOUNT
❑Irti titian - 0 fL 22 tL Portland Cement Tremie
Non:Water Sul pity'VVeM. R. fL
®hdanitaring pRcca��ctg
Injection VYcll:
iL ft.
0Agnifer( .ha;gc I16roum%sutcrltcnlCtlWtion -'19 SANn1GRAVELTACK(if ;a;canre),
FROM TO ntA PRIAL Et�trLACMWN'TM Turn
C]AgnifCr-S1atuFe aixi Itccbvcly []Salinity)3ariicr 25 R. 37 ft. Sand.#2 Pour
17Agaifcr.7est. ASiormtrrtcr Dn,tnago
t7��erintenial Tahnalag}' ,pSrtbsidcrxc Catdml• '2a pRIGLUNGI.OG'falldch:nddl(ioriril stice(s'if nccesmri•T
Mettltennal(Closed Loup) ❑Tratet FROM 170 DESLR;PTtO\ic»;ar.hanr�c�aril'nrck tv n Lyre.Hr t
❑Geuthenual(Fleati!g Cuoilug ReLum). ❑tither(explain under 921 Remades) 0 fL 0.5 fL Gravel
0.5 fL 3-.5 (L Clayey Silt
6-7-2022 MW-4 1'
4.Date Well(s)Cauipielt d: Welt®t/ 3.5 R. 10 (i Silt!
Sa,Well Gtcatlnn: 10 fL 37 ft. Sandy Silt (�NRP Holdings, LLC N/A ft. ft. JUL 2 2 2022
Facility,'4JnncrNnriuc Fnculit?•iDk fiCnppli;,nblcj R. ft.
{(1�pltr1i11SiS-P�Af,�ii�!{
3934 Raleigh St., Charlotte, NC, .28206
Plwskd Mom City.and Zip =2L HF M1(ARKS'• `
Mecklenburg 09107202 3 foot bentonite seal from 22 to 25 feet
Canals• Parc011th ntiE"M dipu No,(PIN)
ib.Latitude aril Longitude in degmeslminutcs/seconds or decimal itcgrct 22.Cetlilieatiion:
pr�.ru;held,Ors I tt+lpi>s Is Ridliclod)
35.150979286 N 80.474843776 7/l/2022
S CVft�d ell Corilmdarii Date
6.Is(are)themcll(yj: XPerntanenr or ❑Temporary 1
Bp s7gnbig rhlrr fafam,.l hereby eerfify rbgr rlae rrrll{s l YYtx{6c icl Cx7attlnrcltrl irr,atYorYLmne
uirh-lsit XCAC 02C.0100 or 1SA kek-d2C,02M Mell Conarsrct(at Srondurdc and xhar a
7.LS'tlas. a ivIlairto sunesiobagwell: Oyes or QONn 'r,7yq}thly rrconiIms&nen proi*W roirm nrll Muller.
ljrhis a-a again fill wr kriaiiw iirll eorurrucdon hrforrnmlon marl topiary ilia"mare_ of Me
rgrui'r&dcr421 remarkr smAin or on the bok ojrhls•farm 23:Site dii*tattt or additional iMl details:
You tray?Me tlie,Gacl;of this pa&to provide additional*:dell"site details or we.11
8.Number of hells constructed: 1 eonsttuctioro details. You niay aLsa auaeft add;Bonat'pages if necessary.
For rurildFle lrZJerilnn or arm-parer snppl wells OjVLr with Lily same constnretlap volt eqo
saomir awe farm. SOBIIEITTAL.iNSTETCTiONS
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9.Total well depth he(ow land surface. 37 (fi) 2U For Ail Wells:. Submit this farm;;";Ilia 30 d ys of completion of flail
For nnrldpreii:0 1(stalldeprlulfdlf-roai errtaMe-3@200'and2@IM7 conslinctionto the foltoinina:
10.Stacie water level below colt of easing,: 27.21 (B,) Division of Water Rtesourcm,Inforrnadou Processing Unit,
1/Haver letrel k eboee msfag,am"+" 1617 hail Sm•ice enter!RLdcigh,NC 27699 617
11,Barcitr►Ic diamctci:8.25" tab.For Enfectinn 1,YclhONLtf in addition to sending tha fomi too lk address•in
24aalrot'e,also submit-a Copy If his font; within 30 days'of completion of w0l
12.Rrcll constmetiou method:BSA eonshuctioo to the follotviun
(i.c.au.-cr.roiary,cable,di>cct pirslt c(c.) Division of Water Itesources.l1ndetguround Injection Control Program,
FOR WATER SUPPLY WELLS ONLY- 1636AfaitSet -ice lCenter,fltaleith,,NC27699-1636
13a,i icld(glim) Methad of test: 24c-For Water Supply&indi ion!`Veils:
Also subtuit one Copp of this frirtit Within 30 days ofcoiupletionof
13h.Disinfection types Amount: well construction to the calm",health department oC the catuttly"here
constructed.
Forio Mr-L Abph Carallna DcpnAnant of Em i[urrrrxnt and;7arursl Rcairrrces-Dii islon of Rratci H�arrcir, Rcc iscd:ltgrr9t_?1113