GW1-2022-10649_Well Construction - GW1_20221128

WELL colVs'ET ucrm RECORD �
For[Iftcmal Ilso ONLY:.
Us.Win can W used W 56gte or Mullipk rsclls'
1'.Welt.CantraUoe•Irtforntatiou:
TLR 2ONlS
Brian Ewing FROM fO DFICRIP1110N
tVelt Co•anicior lti lrne ft. ir, l
4240-B
NC Well ComiactorCenitxalionNun bet IS ®LITER CASING ifiii inuII ravcdwccRsYOR LINER lft a' Gca6kl`
FROM I TO Drab/F.TBR TMC.hNESS I MATERIAL
SAEDACCO Inc fr. fr. i la
(bnrp;ulyKaplc• KANNER CASING OR'TUBING;' ¢oibend:tl ctu�daoil'
FROM TO DLIbfETIiR Tf1ICKNF..S5 v MATERIAL
2:�YcltConst,uctinn['ettuit : 70003075 0 ft. 17 ft. 1" n6 SCH-40
L PVC
si old rip i{able sw)l permits.11 n P.Cnun .Siwp.Y•ariawe.f1*66a3 cL;.)'
ft. ft. Ala
3.Well Ifw(chccl.vvwetl itsc): ;I7---- - -
Water Supply Nell:' FROM ITO nIAAIF.TP11t $WTSWI, I TRICHNUSS I MATCRULI,
CiAgtieultatai ri;NiunicipaU'I'Rl)lic. 10 ft. 27 ft. 111 is .010 SCH-40 PVC PRE-PACK
Meothennal(IlealinglCooling Supply) OR&.denrialWater Supply(single) ft, ft fn
®indttstn tUContntcrcial ®Residential tVSter Supp1}(slz�ted) -t8 CROUT: :.. .r
FROM TO. AtATEItL•til CMPIACEMC\TMMI01)4X%I0UNT
E31rripation f,. ft.
Nou� aferSupplyW�ll: tr, fb
6dhlpnil0ring pR�.gvcly
Injectionivelt; n. ft,.
O ft iferftharge, f_l{rouadvialcr Rclncdiatiou :I9LSAND1GRAVEL.•PACK if.: r rliul,tcy
�. THONI in MATPIUAI. F.MPI,ACLAWNTW-Tnon
17AguifcuSioragc.ord Rceaveiy []Salinity Baftid 15 R, 21 f1, FILTER SAND # 2
❑Ariniier Tcst• 05lnrafivatcr r3r,lir agc
f6• ft.
' ❑E?grc[imcnitlTccltnofn3� (7Stthsidcncc"(�oittml
20:DRILLING LOG fatWeh additional shecli if necesuin•I
OGeodigmytl(ClusedGaup) OTracer FRONT ' TO. I Peii'RIPT1ONfwbrbitidncn,,Ai[Vstwk fr.p'nvce,dr,)
❑Gmthennal(HeaUng(&oling Return) 170dier(explain.urrder,921 Retnaiks) 0 r4 15 f4 FILL SILT AND SAND
15 It. 21 ft. MOIST SILTY SAND.
4.'J rtcW16U(s).Canlpleted: 10-26-22 kVdl�t}TMW-1 ND
ft. fL —
g
5n:WCl[ lcatfoDi ft. ft.
r "
City of Charlotte ft.. ft.
Faciliiy'Ui'v.wrNamo Facfflity 1159(iEapplicilble).. R. ft,
333 Parkwood Ave.., Charlotte, NC, 28206 ft. ft. '.afai '
PL}3i^adAildress Cit}.niidZip '21_RERIARKS
Mecklenburg 08301126 BENTONITE SEAL 13 TO'15'
Cnauis IWce7 No,(PIN)
51i,i atitltdcanil Iaingitadcin atcttccslminutcslFccoil n1 dt itnal ticgrcc�: 22.Certiiicattnn:
(irfyelt P>:W,p1a(aL'141:�,iS srdficicld)
h - WraY1._E1OQf1 11/9j2022
Sigmtu�ofCenified l':ell Contractor,' Dale
6.Is(are)the-v}•ell(s): 17Permanent or MTetuporaiy
signing:rho form„1 hereby errrily Hoyle,the well(s)1•.w•1HcrPl cursurue7rd ur;JtcrorrlrnVe
Ivith[sit,YCAC 01C.0109 a;•1 set XCW 02C.020011 elf Cojunv a&or Sfamdards acid rllar a
7.j5I this a reliaie fu ati'czistin„`e'elt: i7'6'es :lie ®NID, cofrr:rif rfiis iecdni hrrstsrrn proriikd astli++5n�11 nniier.
if rkls.ls a repair,fill air k M01 Well e6minrrrlan hr figrrnr•rlort anti earlabi rk ngnue of die
rrrfrrir raclr.Yd21 rcrrurrds rerrivn or ran the Gtnk of rids jonm -23.Site dla;ram or additional ivell detaih:
You may ace ih'e,bac(t of this P 7bre to provide additional well site details•or%sell.
S:1\ernlberof wells coasrrltcted: 1 collsuucti0u derails. You u>a}a[so-attac[i addidouat Pages if In: liy.
For ritLWgq I'decrlotr orofvi-rarer supply Ieells ONLY iiIrli ifie.sairie coirstrucriwr,you can
srrt7ntir imm jorm. SUBl1RTT'AL W-SI CTIONS i
9.Total well depth Ilelow land surf rep: 27 (ft.) 24% For Alt Wells: Submit this fonn within 30 days of eomptetion'of wellFor multiple 1 e45-ItSt(rll depths ildif,ereiu lesavipfe-3@2W'aru12 a@s 1!}It•) Constriction to the folloi-ing:
10.Stoic water level below trip of casiu;; (tf,j Qlivisiun of Water Resnarcesi Information I?iu essing Unit,;
ljnafft leycJ lrarhove caafug.use•'+" 1617 LHI Sc"nicc Ceatcr,ILdeIgli,vG 27699-1617
11.Irorcheilc diamctcr.2.25" (in) 2�6,Fair Iliferli 11 Weltc ONLY: -Fri addition to•se6ding:the farm to the addlss in
24a above. also submit a copy of this fortis within g0 days"of completion of indll
12.Well cttnstractiou method:DRIVEN Construction to Cite f6flo%V lIv-
(i.e.aupe..'rWaiy.Coble:direct posh etc.)
Wvbloa of Water Ri-sources,Uudcrgmund Irtjection Control Prograut,
FOR WATER SUPPLY%VLLLS ONLY: 1636 hill[Service Ceuler,Raleigh.NC 27699-1636
13;r,Field(g`fm) drethvd of test For Watcr.Supply&rocctian Wells
Also stlbillit ow Copy of this.fonii within 30:day-sofcomplelioa,af
13b.DlsinfeLtion type: Amount _ - _- -__-- - %Ycfl construction to the county health department or the.Colin*'whCM
constnlctcd. i .
Fann G%Nr-I Nonit Carolina Mpartmera of Eavirottmeru and NattuJ Resources-Dihl;lon of Water Rr-xoLrCM Revised stftgust'21)13
i i